Provider Demographics
NPI:1629391693
Name:ELBO, JORRELL-MARK TALADIAR (LMP)
Entity Type:Individual
Prefix:
First Name:JORRELL-MARK
Middle Name:TALADIAR
Last Name:ELBO
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24160 NE STATE ROULTE 3
Mailing Address - Street 2:SUITE 1 & 2
Mailing Address - City:BELFAIR
Mailing Address - State:WA
Mailing Address - Zip Code:98528
Mailing Address - Country:US
Mailing Address - Phone:360-205-3085
Mailing Address - Fax:
Practice Address - Street 1:24160 NE STATE ROUTE 3
Practice Address - Street 2:1 & 2
Practice Address - City:BELFAIR
Practice Address - State:WA
Practice Address - Zip Code:98528-9626
Practice Address - Country:US
Practice Address - Phone:360-205-3085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-05
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60123564225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist