Provider Demographics
NPI:1083074090
Name:ELITE REHAB AND WEIGHTLOSS
Entity Type:Organization
Organization Name:ELITE REHAB AND WEIGHTLOSS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ENNA
Authorized Official - Middle Name:
Authorized Official - Last Name:CULL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-469-5011
Mailing Address - Street 1:45 FAIRWAY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30022-5421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1544 SOUTHLAKE PKWY
Practice Address - Street 2:SUITE 9D
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-3025
Practice Address - Country:US
Practice Address - Phone:678-469-5011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR006798111N00000X
GACHIR006852111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty