Healthcare Provider Details

I. General information

NPI: 1003257601
Provider Name (Legal Business Name): ELEVATE REHAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2013
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 E MAIN ST STE B
LANDER WY
82520-3470
US

IV. Provider business mailing address

545 E MAIN ST STE B
LANDER WY
82520-3470
US

V. Phone/Fax

Practice location:
  • Phone: 307-335-3471
  • Fax: 307-332-5388
Mailing address:
  • Phone: 307-335-3471
  • Fax: 307-332-5388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE L MAZUR
Title or Position: OWNER
Credential:
Phone: 307-335-3471