Provider Demographics
NPI:1780613182
Name:ELLER, THOMAS MARK
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:MARK
Last Name:ELLER
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 1:5000 CHESHIRE LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-3706
Mailing Address - Country:US
Mailing Address - Phone:888-333-9152
Mailing Address - Fax:763-268-4240
Practice Address - Street 1:3399 WEDGEWOOD LN
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32162-7180
Practice Address - Country:US
Practice Address - Phone:352-259-8070
Practice Address - Fax:352-259-8976
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS2734237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist