Healthcare Provider Details

I. General information

NPI: 1245160134
Provider Name (Legal Business Name): ELLIOTT TRISTAN RODGERS OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1129 BOMBAY LN UNIT 8201
MYRTLE BEACH SC
29572-4692
US

IV. Provider business mailing address

546 FIROUZ DR
LONGS SC
29568-6274
US

V. Phone/Fax

Practice location:
  • Phone: 910-789-4532
  • Fax:
Mailing address:
  • Phone: 704-771-8022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number7950
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: