MEDICARE: JESSE ELIS DPT

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	225100000X	Physical Therapist	8515PT	AZ

General Provider Information

NPI Number	:	1851529986
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSE ELIS DPT

Provider Business Mailing Address
First Line	:	7007 E GOLD DUST AVE APT 1080
Second Line	:
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85253-1441
Country	:	US
Telephone Number	:	701-290-8636
Fax Number	:

Provider Business Practice Location Address
First Line	:	5111 N SCOTTSDALE RD UNIT 31
Second Line	:
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85250-7075
Country	:	US
Telephone Number	:	480-990-1379
Fax Number	:

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

Provider Enumeration Date	:	06/26/2009
Last Update Date	:	06/26/2009

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