=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699252247
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIJAH ST JOHN PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2018
-----------------------------------------------------
Last Update Date | 02/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 PALOMA DR
-----------------------------------------------------
City | TEMPLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76502-7650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-204-0522
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6512 BROOKS DR
-----------------------------------------------------
City | TEMPLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76502-6300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-204-0522
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 2098353
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------