MEDICARE: ELITE ALLIANCE PHYSICAL THERAPY PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist
2	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1114692597
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELITE ALLIANCE PHYSICAL THERAPY PLLC

Provider Business Mailing Address
First Line	:	4201 POPPY HILL CT
Second Line	:
City	:	ROWLETT
State	:	TX
Zip	:	75088-6496
Country	:	US
Telephone Number	:	469-531-9697
Fax Number	:

Provider Business Practice Location Address
First Line	:	2629 N STEMMONS FWY STE 225
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75207-2115
Country	:	US
Telephone Number	:	469-531-9697
Fax Number	:

Authorized Official
Title or Position	:	OWNER/FOUNDER
Name	:	DR. EMMANUEL FASANYA JR.
Credential	:	PT, DPT, CSOMT
Telephone Number	:	469-531-9697

Provider Enumeration Date	:	08/09/2021
Last Update Date	:	08/18/2021

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