Healthcare Provider Details

I. General information

NPI: 1063001428
Provider Name (Legal Business Name): ELITE SURGICAL, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2021
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13521 MANE CT
JUSTIN TX
76247-1110
US

IV. Provider business mailing address

13521 MANE CT
JUSTIN TX
76247-1110
US

V. Phone/Fax

Practice location:
  • Phone: 817-917-5651
  • Fax: 940-648-1293
Mailing address:
  • Phone: 817-917-5651
  • Fax: 940-648-1293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINE WALKER
Title or Position: PRESIDENT/OWNER
Credential: RN, BSN, CRNFA, CNOR
Phone: 817-917-5651