Provider Demographics
NPI:1770134132
Name:TELLO, JUSTIN MICHAEL
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:MICHAEL
Last Name:TELLO
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 1:2112 TARPON LANDINGS DR
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34688-6600
Mailing Address - Country:US
Mailing Address - Phone:386-307-6784
Mailing Address - Fax:
Practice Address - Street 1:2112 TARPON LANDINGS DR
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34688-6600
Practice Address - Country:US
Practice Address - Phone:386-307-6784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12893111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor