Healthcare Provider Details

I. General information

NPI: 1134592520
Provider Name (Legal Business Name): MATTHEW ALLEN ELLIOTT PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2015
Last Update Date: 11/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 W BROADWAY AVE
MARYVILLE TN
37801-5402
US

IV. Provider business mailing address

8823 PRODUCTION LN
OOLTEWAH TN
37363-6511
US

V. Phone/Fax

Practice location:
  • Phone: 865-983-8129
  • Fax: 865-983-8293
Mailing address:
  • Phone: 423-238-7217
  • Fax: 423-285-6647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number6157
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: