Provider Demographics
NPI:1720388697
Name:TJELTVEIT, MATT
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:TJELTVEIT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 GALLETTI WAY
Mailing Address - Street 2:BLDG. 8N
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89431-5564
Mailing Address - Country:US
Mailing Address - Phone:775-688-1633
Mailing Address - Fax:775-688-1640
Practice Address - Street 1:480 GALLETTI WAY
Practice Address - Street 2:BLDG. 8N
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89431-5564
Practice Address - Country:US
Practice Address - Phone:775-688-1633
Practice Address - Fax:775-688-1640
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner