Healthcare Provider Details

I. General information

NPI: 1548238801
Provider Name (Legal Business Name): BRIAN DALE ELZA PT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 NIZHONI BLVD
GALLUP NM
87301-5748
US

IV. Provider business mailing address

PO BOX 1337
GALLUP NM
87305-1337
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax: 505-722-1310
Mailing address:
  • Phone: 505-722-1000
  • Fax: 505-722-1310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number20290
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: