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General NPI Number Information
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NPI Number | 1174869259
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Entity Type | Organization
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Legal Business Name | ELITE ORTHO-THERAPY AND SPORTS MEDICINE, LLC
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Dates
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Enumeration Date | 12/18/2012
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Last Update Date | 12/18/2012
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Provider Practice Location Address
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Address Line | 2125 LOUISIANA BLVD NE SUITE 160
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City | ALBUQUERQUE
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State | NM
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Zip | 87110-5416
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Country | US
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Telephone | 505-252-4080
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Fax |
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Provider Business Mailing Address
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Address Line | 2125 LOUISIANA BLVD NE SUITE 160
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City | ALBUQUERQUE
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State | NM
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Zip | 87110-5416
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Country | US
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Telephone | 505-252-4080
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | BEAU B HIGHTOWER
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Credential | DC
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Telephone | 505-252-4080
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 1994
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License Number State | NM
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