Provider Demographics
NPI:1649500265
Name:ELACO, ROLLY GALLEGO (PT)
Entity type:Individual
Prefix:MR
First Name:ROLLY
Middle Name:GALLEGO
Last Name:ELACO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
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Mailing Address - Street 1:42460 SILVERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314-2941
Mailing Address - Country:US
Mailing Address - Phone:313-729-0799
Mailing Address - Fax:586-274-0704
Practice Address - Street 1:38765 MOUND RD
Practice Address - Street 2:SUITE 101
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-3209
Practice Address - Country:US
Practice Address - Phone:586-274-0750
Practice Address - Fax:586-274-0704
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-04
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5501011330225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist