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General NPI Number Information
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NPI Number | 1871963025
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Entity Type | Organization
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Legal Business Name | ELITE PHYSICAL MEDICINE
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Dates
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Enumeration Date | 09/30/2015
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Last Update Date | 09/30/2015
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Provider Practice Location Address
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Address Line | 2711 N HASKELL AVE 2ND FLOOR
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City | DALLAS
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State | TX
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Zip | 75204-2911
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Country | US
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Telephone | 972-885-0440
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Fax | 888-317-7686
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Provider Business Mailing Address
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Address Line | 2535 TYE LN
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City | LEWISVILLE
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State | TX
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Zip | 75056-3936
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Country | US
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Telephone | 972-339-2464
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF PHYSICAL MEDICINE
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Name | BRADLEY ALLEN HALL
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Credential | D.C.
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Telephone | 972-339-2464
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 12049
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License Number State | TX
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