=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962601724
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE HEALTHCARE GROUP P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2007
-----------------------------------------------------
Last Update Date | 03/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1335 FLOWERING DOGWOOD LANE
-----------------------------------------------------
City | DYERSBURG
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-286-2467
-----------------------------------------------------
Fax | 731-286-1178
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1335 FLOWERING DOGWOOD LANE
-----------------------------------------------------
City | DYERSBURG
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-286-2467
-----------------------------------------------------
Fax | 731-286-1178
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR - OWNERSHIP
-----------------------------------------------------
Name | MR. JOHN NOBLIN
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 731-286-2467
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC562
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------