MEDICARE: ELITE TREATMENT CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician
2	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1497370092
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELITE TREATMENT CENTER, INC.

Provider Business Mailing Address
First Line	:	395 W LINCOLN HWY
Second Line	:
City	:	CHICAGO HEIGHTS
State	:	IL
Zip	:	60411-2442
Country	:	US
Telephone Number	:	773-597-7698
Fax Number	:

Provider Business Practice Location Address
First Line	:	395 W LINCOLN HWY
Second Line	:
City	:	CHICAGO HEIGHTS
State	:	IL
Zip	:	60411-2442
Country	:	US
Telephone Number	:	773-597-7698
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM DIRECTOR
Name	:	MISS CHRISTINE ELLIS
Credential	:
Telephone Number	:	708-781-3155

Provider Enumeration Date	:	06/10/2020
Last Update Date	:	06/10/2020

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