Healthcare Provider Details

I. General information

NPI: 1538896022
Provider Name (Legal Business Name): ELITE PHYSICAL THERAPY AND SPORTS MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 PARK EAST BLVD STE B
LAFAYETTE IN
47905-0811
US

IV. Provider business mailing address

823 PARK EAST BLVD STE B
LAFAYETTE IN
47905-0811
US

V. Phone/Fax

Practice location:
  • Phone: 765-297-0975
  • Fax: 765-297-0974
Mailing address:
  • Phone: 765-297-0975
  • Fax: 765-297-0974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: BRAD BAISDEN
Title or Position: OWNER
Credential: PT
Phone: 765-297-0975