Healthcare Provider Details

I. General information

NPI: 1669736120
Provider Name (Legal Business Name): ELITE HEALTHCARE PHYSICAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2012
Last Update Date: 06/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 ADAMSON SQ
CARROLLTON GA
30117-3213
US

IV. Provider business mailing address

307 ADAMSON SQ
CARROLLTON GA
30117-3213
US

V. Phone/Fax

Practice location:
  • Phone: 770-214-9146
  • Fax: 770-214-9166
Mailing address:
  • Phone: 770-214-9146
  • Fax: 770-214-9166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberCHIR007565
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN148627
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number052922
License Number StateGA

VIII. Authorized Official

Name: DR. RYAN C WEBER
Title or Position: OWNER
Credential:
Phone: 770-214-9146