Healthcare Provider Details

I. General information

NPI: 1508297003
Provider Name (Legal Business Name): ELITECARE OF FAYETTEVILLE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

3622 N MAIN ST
HOPE MILLS NC
28348-1937
US

IV. Provider business mailing address

3622 N MAIN ST
HOPE MILLS NC
28348-1937
US

V. Phone/Fax

Practice location:
  • Phone: 910-423-7771
  • Fax: 910-423-4177
Mailing address:
  • Phone: 910-423-7771
  • Fax: 910-423-4177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. TRAVIS SANDERS ROSS
Title or Position: ORGANIZER/MEMBER
Credential: PA
Phone: 910-551-8882