Provider Demographics
NPI:1316179021
Name:ELMORE, TOVAN WILLEY (ATC)
Entity Type:Individual
Prefix:
First Name:TOVAN
Middle Name:WILLEY
Last Name:ELMORE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:TOVAN
Other - Middle Name:JESSICA
Other - Last Name:WILLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:900 GARDEN MEADOWS CT
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-8986
Mailing Address - Country:US
Mailing Address - Phone:516-417-4832
Mailing Address - Fax:
Practice Address - Street 1:900 GARDEN MEADOWS CT
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-8986
Practice Address - Country:US
Practice Address - Phone:516-417-4832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA16592255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer