MEDICARE: TIFFANY AMBER ELO PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208100000X	Physical Medicine & Rehabilitation Physician	5502008270	MI

General Provider Information

NPI Number	:	1114601366
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY AMBER ELO PTA

Provider Business Mailing Address
First Line	:	2000 LEONARD ST NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49505-5837
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1771 KNAPP ST NE UNIT 2
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49505-4501
Country	:	US
Telephone Number	:	231-510-1410
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2023
Last Update Date	:	06/09/2023

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Directions to “ TIFFANY AMBER ELO PTA” Practice Location

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