Healthcare Provider Details

I. General information

NPI: 1053844753
Provider Name (Legal Business Name): ELITE ANKLE AND FOOT PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2017
Last Update Date: 04/18/2024
Certification Date: 04/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 E CENTER STREET
GUNNISON UT
84634
US

IV. Provider business mailing address

39 E CENTER STREET
GUNNISON UT
84634
US

V. Phone/Fax

Practice location:
  • Phone: 844-626-2455
  • Fax: 844-626-2455
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number9141980-0501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number9141980-0501
License Number StateUT

VIII. Authorized Official

Name: TYLER JOLLEY
Title or Position: DPM
Credential:
Phone: 435-462-3668