Healthcare Provider Details

I. General information

NPI: 1841594900
Provider Name (Legal Business Name): ELITE SPECIALTY CLINICS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2011
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 MAIN ST
WILLISTON ND
58801-5316
US

IV. Provider business mailing address

512 MAIN ST
WILLISTON ND
58801-5316
US

V. Phone/Fax

Practice location:
  • Phone: 701-774-0320
  • Fax:
Mailing address:
  • Phone: 701-774-0320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number1089
License Number StateND

VIII. Authorized Official

Name: DR. MARTIN JOHN HAUG
Title or Position: PRESIDENT/OWNER
Credential: PT, ATC
Phone: 701-770-0906