Basic Information
| Provider Information | |||||||||
| NPI: | 1508126434 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELENBAAS | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | GARRETT | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1695 | ||||||||
| Address2: | |||||||||
| City: | HOLLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494221695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163923197 | ||||||||
| FaxNumber: | 6163927959 | ||||||||
| Practice Location | |||||||||
| Address1: | 3491 LINCOLN RD | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494199512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2697512150 | ||||||||
| FaxNumber: | 2697512140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2012 | ||||||||
| LastUpdateDate: | 05/25/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 5502003533 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.