1457756702 NPI number — ELITE PERFORMANCE SPORTS AND PHYSICAL THERAPY, INC.

Table of content: (NPI 1457756702)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457756702 NPI number — ELITE PERFORMANCE SPORTS AND PHYSICAL THERAPY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELITE PERFORMANCE SPORTS AND PHYSICAL THERAPY, INC.
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:
6
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:
1457756702
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6526 LONETREE BLVD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
ROCKLIN
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95765-5886
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-772-2909
Provider Business Mailing Address Fax Number:
916-772-2989

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6526 LONETREE BLVD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
ROCKLIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95765-5886
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-772-2909
Provider Business Practice Location Address Fax Number:
916-772-2989
Provider Enumeration Date:
10/29/2014

Additional Information

Authorized Official

Authorized Official Last Name:
GULBRANDSON
Authorized Official First Name:
CHRIS
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
916-765-5661

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X , with the licence number:  PT28076 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT28076 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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