Healthcare Provider Details

I. General information

NPI: 1083174007
Provider Name (Legal Business Name): TREVOR ROBERT ELMITT LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 03/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 E GETWELL LOOP
MEMPHIS TN
38152-4210
US

IV. Provider business mailing address

431 S HIGHLAND ST APT 422
MEMPHIS TN
38111-1645
US

V. Phone/Fax

Practice location:
  • Phone: 901-678-3536
  • Fax:
Mailing address:
  • Phone: 515-314-6569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2211
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: