Healthcare Provider Details

I. General information

NPI: 1699821439
Provider Name (Legal Business Name): ELITE MUSCULAR THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W EVERGREEN BLVD STE 500
VANCOUVER WA
98660-3453
US

IV. Provider business mailing address

210 W. EVERGREEN SUITE 500
VANCOUVER WA
98660
US

V. Phone/Fax

Practice location:
  • Phone: 360-693-3863
  • Fax: 360-693-6894
Mailing address:
  • Phone: 360-693-3863
  • Fax: 360-693-6894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateWA

VIII. Authorized Official

Name: DEBORAH L BANKS
Title or Position: PRESIDENT
Credential: LMP
Phone: 360-693-3863