=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205792850
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE REHAB, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2025
-----------------------------------------------------
Last Update Date | 12/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 616 E SHEPHERD AVE
-----------------------------------------------------
City | KIRKSVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63501-4711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-216-8199
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29559 KATYDID ST
-----------------------------------------------------
City | LA PLATA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63549-3202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICAL THERAPIST
-----------------------------------------------------
Name | BRANDON MACK
-----------------------------------------------------
Credential | DPT, OCS
-----------------------------------------------------
Telephone | 660-216-8199
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------