Healthcare Provider Details

I. General information

NPI: 1265980296
Provider Name (Legal Business Name): BRITTANY JACQUELYN ELMORE ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2016
Last Update Date: 09/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 N 3RD ST
CENTRAL POINT OR
97502-1876
US

IV. Provider business mailing address

563 BERRYDALE AVE
MEDFORD OR
97501-1619
US

V. Phone/Fax

Practice location:
  • Phone: 541-630-0705
  • Fax:
Mailing address:
  • Phone: 541-670-0113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-AT-10158622
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: