1467687806 NPI number — ELITE SPORTS MEDICINE INSTITUTE, LTD.

Table of content: (NPI 1467687806)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467687806 NPI number — ELITE SPORTS MEDICINE INSTITUTE, LTD.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELITE SPORTS MEDICINE INSTITUTE, LTD.
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:
1467687806
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3231
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK BROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60522-3231
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-789-3764
Provider Business Mailing Address Fax Number:
630-794-9998

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
760 PASQUINELLI DR
Provider Second Line Business Practice Location Address:
SUITE 304
Provider Business Practice Location Address City Name:
WESTMONT
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60559-5564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-789-3764
Provider Business Practice Location Address Fax Number:
630-794-9998
Provider Enumeration Date:
05/28/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MODY
Authorized Official First Name:
KETAN
Authorized Official Middle Name:
RAJENDRA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
630-789-3764

Provider Taxonomy Codes

  • Taxonomy code: 207QS0010X , with the licence number:  036119306 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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