MEDICARE: ELITE PHYSICAL THERAPY AND WELLNESS

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	261QP2000X	Physical Therapy Clinic/Center	5501011436	MI

General Provider Information

NPI Number	:	1912059700
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELITE PHYSICAL THERAPY AND WELLNESS

Provider Business Mailing Address
First Line	:	4053 S LAPEER RD
Second Line	:	SUITE C
City	:	METAMORA
State	:	MI
Zip	:	48455-8721
Country	:	US
Telephone Number	:	810-678-3202
Fax Number	:

Provider Business Practice Location Address
First Line	:	4053 S LAPEER RD
Second Line	:	SUITE C
City	:	METAMORA
State	:	MI
Zip	:	48455-8721
Country	:	US
Telephone Number	:	810-678-3202
Fax Number	:	810-678-3205

Authorized Official
Title or Position	:	EXECUTIVE OFFICER
Name	:	DR. JEFFREY JOHN JACOB
Credential	:	D.P.T.
Telephone Number	:	810-441-3033

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	04/02/2014

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Directions to “ELITE PHYSICAL THERAPY AND WELLNESS ” Practice Location

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