=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407297922
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE PHYSICAL THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2013
-----------------------------------------------------
Last Update Date | 07/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2189 MORRISON AVE
-----------------------------------------------------
City | UNION
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07083-5207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-590-2620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2189 MORRISON AVE
-----------------------------------------------------
City | UNION
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07083-5207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-590-2620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MOHAMED MASOUD
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 908-590-2620
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 40QA01283500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------