=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841481736
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE PHYSICAL THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2007
-----------------------------------------------------
Last Update Date | 05/28/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 RUSHMORE DR
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29615-1255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-233-5128
-----------------------------------------------------
Fax | 864-271-2599
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1011 GROVE RD SUITE 2A
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29605-4660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-233-5128
-----------------------------------------------------
Fax | 864-271-2599
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / PHYSICAL THERAPIST
-----------------------------------------------------
Name | ROBERT PAUL HECKER
-----------------------------------------------------
Credential | MSPT
-----------------------------------------------------
Telephone | 864-233-5128
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT4585
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------