Healthcare Provider Details

I. General information

NPI: 1457756702
Provider Name (Legal Business Name): ELITE PERFORMANCE SPORTS AND PHYSICAL THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2014
Last Update Date: 12/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6526 LONETREE BLVD SUITE 200
ROCKLIN CA
95765-5886
US

IV. Provider business mailing address

6526 LONETREE BLVD SUITE 200
ROCKLIN CA
95765-5886
US

V. Phone/Fax

Practice location:
  • Phone: 916-772-2909
  • Fax: 916-772-2989
Mailing address:
  • Phone: 916-772-2909
  • Fax: 916-772-2989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT28076
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT28076
License Number StateCA

VIII. Authorized Official

Name: MR. CHRIS J GULBRANDSON
Title or Position: OWNER
Credential: MPT
Phone: 916-765-5661