Basic Information
| Provider Information | |||||||||
| NPI: | 1003015058 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELMORE | ||||||||
| FirstName: | LEANN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | LMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 650124 | ||||||||
| Address2: | |||||||||
| City: | VERO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329650124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7728829773 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8840 44TH AVE | ||||||||
| Address2: | |||||||||
| City: | SEBASTIAN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329587556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7728829773 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2007 | ||||||||
| LastUpdateDate: | 09/29/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | MA41181 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
ID Information
| ID | Type | State | Issuer | Description | C3752 | 01 | FL | BLUE CROSS & BLUE SHIELD | OTHER |