Provider Demographics
NPI:1730908807
Name:TEATER, ELI KENAN
Entity type:Individual
Prefix:
First Name:ELI
Middle Name:KENAN
Last Name:TEATER
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 1:4326 VINCE RD
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-9440
Mailing Address - Country:US
Mailing Address - Phone:859-797-9760
Mailing Address - Fax:
Practice Address - Street 1:4326 VINCE RD
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-9440
Practice Address - Country:US
Practice Address - Phone:859-797-9760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer