Healthcare Provider Details

I. General information

NPI: 1417417163
Provider Name (Legal Business Name): ELITE PERFORMANCE INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 03/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19719 LEITERSBURG PIKE
HAGERSTOWN MD
21742-1443
US

IV. Provider business mailing address

19719 LEITERSBURG PIKE
HAGERSTOWN MD
21742-1443
US

V. Phone/Fax

Practice location:
  • Phone: 434-964-6952
  • Fax:
Mailing address:
  • Phone: 434-964-6952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN PUGH
Title or Position: CO-OWNER / PHYSICAL THERAPIST
Credential: DPT, ATC, SCS
Phone: 434-964-6952