1821256298 NPI number — ELITE PHYSICAL THERAPY GROUP, LLC

Table of content: (NPI 1821256298)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821256298 NPI number — ELITE PHYSICAL THERAPY GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELITE PHYSICAL THERAPY GROUP, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821256298
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21707 103RD AVENUE CT E STE B202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAHAM
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98338-8308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-271-7339
Provider Business Mailing Address Fax Number:
253-655-5845

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
223 140TH ST S STE 700
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98444-4549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-531-5645
Provider Business Practice Location Address Fax Number:
253-536-3467
Provider Enumeration Date:
06/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PETTINGILL
Authorized Official First Name:
TREVOR
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
PHYSICAL THERAPIST/CLINIC OWNER
Authorized Official Telephone Number:
253-732-8116

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  602832882 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: G8876026 . This is a "MEDICARE PTAN #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2001745 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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