Healthcare Provider Details

I. General information

NPI: 1912059700
Provider Name (Legal Business Name): ELITE PHYSICAL THERAPY AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 04/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4053 S LAPEER RD SUITE C
METAMORA MI
48455-8721
US

IV. Provider business mailing address

4053 S LAPEER RD SUITE C
METAMORA MI
48455-8721
US

V. Phone/Fax

Practice location:
  • Phone: 810-678-3202
  • Fax: 810-678-3205
Mailing address:
  • Phone: 810-678-3202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number5501011436
License Number StateMI

VIII. Authorized Official

Name: DR. JEFFREY JOHN JACOB
Title or Position: EXECUTIVE OFFICER
Credential: D.P.T.
Phone: 810-441-3033