Healthcare Provider Details

I. General information

NPI: 1811672686
Provider Name (Legal Business Name): ELITE DCR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2023
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 S ALVARADO ST
LOS ANGELES CA
90057-2904
US

IV. Provider business mailing address

510 S ALVARADO ST
LOS ANGELES CA
90057-2904
US

V. Phone/Fax

Practice location:
  • Phone: 213-483-3600
  • Fax: 213-483-4555
Mailing address:
  • Phone: 213-483-3600
  • Fax: 213-483-4555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM MARTINEZ
Title or Position: PRESIDENT
Credential: PA-C
Phone: 213-483-3600