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General NPI Number Information
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NPI Number | 1386982452
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Entity Type | Individual
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Provider Name | ELIJAH MATTHEW HILLSTROM C.PED
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Gender | Male
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Dates
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Enumeration Date | 01/24/2013
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Last Update Date | 01/24/2013
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Provider Practice Location Address
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Address Line | 4903 NE ST JOHNS RD
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City | VANCOUVER
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State | WA
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Zip | 98661-2546
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Country | US
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Telephone | 360-635-8079
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Fax | 360-450-2236
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Provider Business Mailing Address
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Address Line | 3816 NE 38TH AVE
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City | VANCOUVER
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State | WA
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Zip | 98661-3426
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Country | US
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Telephone | 360-635-8079
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Fax | 360-450-2236
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224L00000X
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Taxonomy Name | Pedorthist
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License Number | CPED3653
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License Number State | WA
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