Healthcare Provider Details

I. General information

NPI: 1568905248
Provider Name (Legal Business Name): ELITE SPORTS MEDICINE AND ORTHOPAEDIC CENTER, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2016
Last Update Date: 07/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 GLIDEPATH WAY
LEBANON TN
37090-4133
US

IV. Provider business mailing address

PO BOX 896172
CHARLOTTE NC
28289-6172
US

V. Phone/Fax

Practice location:
  • Phone: 615-324-1600
  • Fax: 615-284-2003
Mailing address:
  • Phone: 615-324-1600
  • Fax: 615-284-2003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number
License Number StateTN
# 5
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number StateTN
# 6
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number StateTN

VIII. Authorized Official

Name: CLAUDIA LAGACY
Title or Position: OFFICE MANAGER
Credential:
Phone: 615-342-0264