Basic Information
| Provider Information | |||||||||
| NPI: | 1518985282 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELITE SPORT & SPINE PHYSICAL THERAPY, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAPP'S PHYSICAL THERAPY SERVICES, INC. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 MASHBURN ST | ||||||||
| Address2: | |||||||||
| City: | HAWKINSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310364961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782927865 | ||||||||
| FaxNumber: | 4787834466 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 MASHBURN ST STE 102 | ||||||||
| Address2: | |||||||||
| City: | HAWKINSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310364961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782927865 | ||||||||
| FaxNumber: | 4787834466 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 12/07/2018 | ||||||||
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| AuthorizedOfficialLastName: | SAPP | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | MELVIN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4782927865 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000754619B | 05 | GA | MEDICAID |