Basic Information
Provider Information | |||||||||
NPI: | 1427440015 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ELITE SURGICAL ASSISTING LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2550 | ||||||||
Address2: |   | ||||||||
City: | ROWLETT | ||||||||
State: | TX | ||||||||
PostalCode: | 750302550 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2142272457 | ||||||||
FaxNumber: | 2147640880 | ||||||||
Practice Location | |||||||||
Address1: | 2442 PLANTERS MILL WAY | ||||||||
Address2: |   | ||||||||
City: | CONYERS | ||||||||
State: | GA | ||||||||
PostalCode: | 300123691 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2142272457 | ||||||||
FaxNumber: | 2147640880 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/19/2015 | ||||||||
LastUpdateDate: | 01/07/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JOSEPH | ||||||||
AuthorizedOfficialFirstName: | BRADFORD | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 2142272457 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CSFA | ||||||||
NPICertificationDate: | 01/07/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
No ID Information.