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General NPI Number Information
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NPI Number | 1427343383
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Entity Type | Organization
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Legal Business Name | ELITE PHYSICAL THERAPY AND SPORTS PERFORMANCE
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Dates
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Enumeration Date | 06/17/2011
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Last Update Date | 09/14/2011
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Provider Practice Location Address
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Address Line | 4177 VILLAGE PARK DR SUITE B
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City | TRAVERSE CITY
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State | MI
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Zip | 49685-7237
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Country | US
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Telephone | 231-590-1364
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Fax |
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Provider Business Mailing Address
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Address Line | 4177 VILLAGE PARK DR SUITE B
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City | TRAVERSE CITY
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State | MI
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Zip | 49685-7237
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Country | US
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Telephone | 231-590-1364
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Fax |
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Authorized Official
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Title or Position | OWNER/MEMBER MANAGER
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Name | MR. JOSEPH MICHAEL HEILER
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Credential | MSPT
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Telephone | 231-590-1364
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 5501009481
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License Number State | MI
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