Healthcare Provider Details

I. General information

NPI: 1740586015
Provider Name (Legal Business Name): ELITE SPORTS MEDICINE PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2011
Last Update Date: 02/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7125 NEW SANGER RD STE B
WACO TX
76712-4054
US

IV. Provider business mailing address

7125 NEW SANGER RD STE B
WACO TX
76712-4054
US

V. Phone/Fax

Practice location:
  • Phone: 254-754-0375
  • Fax: 205-754-2667
Mailing address:
  • Phone: 254-754-0375
  • Fax: 205-754-2667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number State

VIII. Authorized Official

Name: ROBERT WOLF
Title or Position: PRESIDENT
Credential: MD
Phone: 205-259-3991