=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275071169
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2017
-----------------------------------------------------
Last Update Date | 02/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 E ORANGEBURG AVE STE E
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95350-5355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-985-3495
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 E ORANGEBURG AVE STE E
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95350-5355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-985-3495
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | ABHA A POHWANI
-----------------------------------------------------
Credential | PT/MS
-----------------------------------------------------
Telephone | 209-985-3495
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 29454
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------