MEDICARE: PHENIX CITY ELITE REHAB SOLUTIONS LLC

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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1669059788
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHENIX CITY ELITE REHAB SOLUTIONS LLC

Provider Business Mailing Address
First Line	:	5409 SUMMERVILLE RD STE 3
Second Line	:
City	:	PHENIX CITY
State	:	AL
Zip	:	36867-7437
Country	:	US
Telephone Number	:	334-947-1327
Fax Number	:	334-408-2460

Provider Business Practice Location Address
First Line	:	5409 SUMMERVILLE RD STE 3
Second Line	:
City	:	PHENIX CITY
State	:	AL
Zip	:	36867-7437
Country	:	US
Telephone Number	:	334-947-1327
Fax Number	:	334-408-2460

Authorized Official
Title or Position	:	DIR OF CREDENTIALING
Name	:	PAMELA VAN ETTEN
Credential	:
Telephone Number	:	334-799-5853

Provider Enumeration Date	:	03/25/2021
Last Update Date	:	04/24/2025

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