Healthcare Provider Details

I. General information

NPI: 1093811408
Provider Name (Legal Business Name): ELITE SPORTS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 07/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1519 CENTRAL ST
STOUGHTON MA
02072-4415
US

IV. Provider business mailing address

1519 CENTRAL ST
STOUGHTON MA
02072-4415
US

V. Phone/Fax

Practice location:
  • Phone: 781-297-0979
  • Fax: 781-297-3703
Mailing address:
  • Phone: 781-297-0979
  • Fax: 781-297-3703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number51
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number51
License Number StateMA

VIII. Authorized Official

Name: KEITH EDWARD CALLANAN
Title or Position: PRESIDENT
Credential: MPT
Phone: 781-297-0979