Provider Demographics
NPI:1801841630
Name:ELO, KEVIN S (PT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:S
Last Name:ELO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3673 EUREKA WAY
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-0177
Mailing Address - Country:US
Mailing Address - Phone:530-533-5030
Mailing Address - Fax:530-213-5970
Practice Address - Street 1:3673 EUREKA WAY
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0177
Practice Address - Country:US
Practice Address - Phone:530-533-5030
Practice Address - Fax:530-213-5970
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05005012A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN555850034Medicare PIN
IN230220Medicare ID - Type Unspecified