=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568780021
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE PHYSICAL THERAPY CENTER INCORPORATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2010
-----------------------------------------------------
Last Update Date | 05/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1665 S IMPERIAL AVE SUITE C
-----------------------------------------------------
City | EL CENTRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92243-4253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-337-8300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2738
-----------------------------------------------------
City | EL CENTRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92244-2738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-337-8300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MR. HALIM OSCAR MARRUJO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 760-337-8300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT26541
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------