=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114949187
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE WHEELCHAIR PRODUCTS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 703 BASCOMB COMMERCIAL PKWY STE 104
-----------------------------------------------------
City | WOODSTOCK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30189-2447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-494-0456
-----------------------------------------------------
Fax | 678-494-0412
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 703 BASCOMB COMMERCIAL PKWY STE 104
-----------------------------------------------------
City | WOODSTOCK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30189-2447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-494-0456
-----------------------------------------------------
Fax | 678-494-0412
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. PHILLIP A GRIGGS
-----------------------------------------------------
Credential | ATS/CRTS
-----------------------------------------------------
Telephone | 678-494-0456
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 20218
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------