Provider Demographics
NPI:1174036065
Name:TIDWELL, ELTON (DPT)
Entity Type:Individual
Prefix:
First Name:ELTON
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6397 LEE HWY
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2564
Mailing Address - Country:US
Mailing Address - Phone:423-238-7211
Mailing Address - Fax:
Practice Address - Street 1:8905 TOWN AND COUNTRY CIR STE 9
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4931
Practice Address - Country:US
Practice Address - Phone:856-539-9185
Practice Address - Fax:865-694-3142
Is Sole Proprietor?:No
Enumeration Date:2017-11-14
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11558225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist