Healthcare Provider Details

I. General information

NPI: 1811461759
Provider Name (Legal Business Name): NATHAN ALEXANDER ELLIOTT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2019
Last Update Date: 01/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1870 QUAKER WAY
WILMINGTON OH
45177-2473
US

IV. Provider business mailing address

281 E MAIN ST UNIT 7B
CLARKSVILLE OH
45113-8311
US

V. Phone/Fax

Practice location:
  • Phone: 937-825-6906
  • Fax:
Mailing address:
  • Phone: 937-825-6906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: