=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235478991
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE PHYSICAL MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2013
-----------------------------------------------------
Last Update Date | 01/31/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 217 EL CAMINO REAL
-----------------------------------------------------
City | TUSTIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92780-3603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-731-9355
-----------------------------------------------------
Fax | 714-544-1538
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 217 EL CAMINO REAL
-----------------------------------------------------
City | TUSTIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92780-3603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-731-9355
-----------------------------------------------------
Fax | 714-544-1538
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC DIRECTOR
-----------------------------------------------------
Name | DR. SEAN O MILAM
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 714-731-9355
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207XX0005X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------