Healthcare Provider Details

I. General information

NPI: 1881468817
Provider Name (Legal Business Name): ELEVATED PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2023
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 S DE LACEY AVE
PASADENA CA
91105-2053
US

IV. Provider business mailing address

188 S DE LACEY AVE
PASADENA CA
91105-2053
US

V. Phone/Fax

Practice location:
  • Phone: 626-360-2717
  • Fax:
Mailing address:
  • Phone: 626-360-2717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MADISON MACKENZIE BURKE
Title or Position: CEO
Credential: PT, DPT
Phone: 626-360-2717