Provider Demographics
NPI:1245008788
Name:ELBA, ARCHIBALD JENALD
Entity type:Individual
Prefix:
First Name:ARCHIBALD
Middle Name:JENALD
Last Name:ELBA
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 1:1785 S HAYES ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22202-2714
Mailing Address - Country:US
Mailing Address - Phone:703-920-5700
Mailing Address - Fax:
Practice Address - Street 1:1785 S. HAYES ST
Practice Address - Street 2:1785 S. HAYES ST
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22202
Practice Address - Country:US
Practice Address - Phone:703-920-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119010249225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty