Basic Information
| Provider Information | |||||||||
| NPI: | 1093811408 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELITE SPORTS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ELITE SPORTS AND PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1519 CENTRAL ST | ||||||||
| Address2: | |||||||||
| City: | STOUGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020724415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812970979 | ||||||||
| FaxNumber: | 7812973703 | ||||||||
| Practice Location | |||||||||
| Address1: | 1519 CENTRAL ST | ||||||||
| Address2: | |||||||||
| City: | STOUGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020724415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812970979 | ||||||||
| FaxNumber: | 7812973703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 07/12/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CALLANAN | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
| AuthorizedOfficialMiddleName: | EDWARD | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7812970979 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MPT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 51 | MA | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | 51 | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | Y61307 | 01 | MA | BCBS | OTHER |