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General NPI Number Information
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NPI Number | 1629391693
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Entity Type | Individual
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Provider Name | JORRELL-MARK TALADIAR ELBO L.M.P.
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Gender | Male
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Dates
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Enumeration Date | 03/05/2010
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Last Update Date | 03/05/2010
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Provider Practice Location Address
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Address Line | 24160 NE STATE ROUTE 3 1 & 2
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City | BELFAIR
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State | WA
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Zip | 98528-9626
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Country | US
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Telephone | 360-205-3085
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Fax |
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Provider Business Mailing Address
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Address Line | 24160 NE STATE ROULTE 3 SUITE 1 & 2
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City | BELFAIR
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State | WA
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Zip | 98528
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Country | US
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Telephone | 360-205-3085
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Fax |
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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 | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MA60123564
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License Number State | WA
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