Healthcare Provider Details

I. General information

NPI: 1477969574
Provider Name (Legal Business Name): ELITE PHYSIQUE PERFORMANCE TRAINING, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2014
Last Update Date: 07/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5740 NIGHT WHISPER RD NW
ALBUQUERQUE NM
87114-1575
US

IV. Provider business mailing address

2325 CORTINA LOOP SE
RIO RANCHO NM
87124-8933
US

V. Phone/Fax

Practice location:
  • Phone: 505-377-7539
  • Fax:
Mailing address:
  • Phone: 505-377-7539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number11423NMPFT
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number11423NMPFT
License Number StateNM

VIII. Authorized Official

Name: STEVEN NEWMAN
Title or Position: PRESIDENT / OWNER
Credential:
Phone: 505-377-7539