1659792836 NPI number — ELITE PHYSICAL THERAPY AND PILATES REHABILITATION PC

Table of content: (NPI 1659792836)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659792836 NPI number — ELITE PHYSICAL THERAPY AND PILATES REHABILITATION PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELITE PHYSICAL THERAPY AND PILATES REHABILITATION PC
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:
1659792836
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2851 S AVENUE B STE 2402
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YUMA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85364-7726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-391-9477
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2851 S AVENUE B STE 2402
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YUMA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85364-7726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-276-4178
Provider Business Practice Location Address Fax Number:
928-276-4172
Provider Enumeration Date:
12/14/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BANCALE
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
LEIGH
Authorized Official Title or Position:
PHYSICAL THERAPIST ASSISTAN
Authorized Official Telephone Number:
800-391-9477

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  10760A , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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