Healthcare Provider Details

I. General information

NPI: 1841307212
Provider Name (Legal Business Name): MR. THOMAS AMOS ELLIOTT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 05/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

POB 1191 1113 DAINGERFIELD ST
TAPPAHANNOCK VA
22560-1191
US

IV. Provider business mailing address

POB 1191 1113 DAINGERFIELD STREET
TAPPAHANNOCK VA
22560-1191
US

V. Phone/Fax

Practice location:
  • Phone: 703-861-4997
  • Fax: 804-445-1914
Mailing address:
  • Phone: 571-501-8865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number2705057306
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: