Provider Demographics
NPI:1093811408
Name:ELITE SPORTS, INC.
Entity Type:Organization
Organization Name:ELITE SPORTS, INC.
Other - Org Name:ELITE SPORTS AND PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:CALLANAN
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:781-297-0979
Mailing Address - Street 1:1519 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072-4415
Mailing Address - Country:US
Mailing Address - Phone:781-297-0979
Mailing Address - Fax:781-297-3703
Practice Address - Street 1:1519 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:MA
Practice Address - Zip Code:02072-4415
Practice Address - Country:US
Practice Address - Phone:781-297-0979
Practice Address - Fax:781-297-3703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA51225100000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY61307OtherBCBS
MAPT0187Medicare ID - Type Unspecified