Healthcare Provider Details

I. General information

NPI: 1194620211
Provider Name (Legal Business Name): ELITE SPORTS PT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 POWERLINE RD
FORT LAUDERDALE FL
33309-3172
US

IV. Provider business mailing address

11821 NW 31ST PL
SUNRISE FL
33323-1210
US

V. Phone/Fax

Practice location:
  • Phone: 754-307-4107
  • Fax:
Mailing address:
  • Phone: 754-307-4107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: RYAN JOHNSON
Title or Position: OWNER
Credential: PT, DPT, CSCS
Phone: 360-525-8349