=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184258436
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELEMENTAL TELEHEALTH, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2020
-----------------------------------------------------
Last Update Date | 04/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3030 BRIDGEWAY STE 101
-----------------------------------------------------
City | SAUSALITO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94965-2810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-594-6548
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3030 BRIDGEWAY STE 101
-----------------------------------------------------
City | SAUSALITO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94965-2810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. EMILY BRUCIA
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 626-594-6548
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------