Healthcare Provider Details

I. General information

NPI: 1740859875
Provider Name (Legal Business Name): MICHAEL ELLIOTT ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2021
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 S 500 W
SALT LAKE CITY UT
84115-5149
US

IV. Provider business mailing address

1531 E KENSINGTON AVE
SALT LAKE CITY UT
84105-2803
US

V. Phone/Fax

Practice location:
  • Phone: 602-999-7738
  • Fax:
Mailing address:
  • Phone: 602-999-7738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number070202240
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: