Provider Demographics
NPI:1164594859
Name:ELITE PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:ELITE PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT CO OWNER PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:VANDIVER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:706-335-3816
Mailing Address - Street 1:205 MERCER PL
Mailing Address - Street 2:HOMER ROAD
Mailing Address - City:COMMERCE
Mailing Address - State:GA
Mailing Address - Zip Code:30529-1564
Mailing Address - Country:US
Mailing Address - Phone:706-335-3816
Mailing Address - Fax:706-335-3819
Practice Address - Street 1:205 MERCER PL
Practice Address - Street 2:HOMER ROAD
Practice Address - City:COMMERCE
Practice Address - State:GA
Practice Address - Zip Code:30529-1564
Practice Address - Country:US
Practice Address - Phone:706-335-3816
Practice Address - Fax:706-335-3819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT004868225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00981439AMedicaid
GA00981439AMedicaid