Provider Demographics
NPI:1164722716
Name:ELITE HEALTH AND WELLNESS LLC
Entity Type:Organization
Organization Name:ELITE HEALTH AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:TATRO
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:802-393-9115
Mailing Address - Street 1:248 N MAIN ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SAINT ALBANS
Mailing Address - State:VT
Mailing Address - Zip Code:05478-1554
Mailing Address - Country:US
Mailing Address - Phone:802-782-8547
Mailing Address - Fax:
Practice Address - Street 1:248 N MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-1554
Practice Address - Country:US
Practice Address - Phone:802-782-8547
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-29
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0400003460225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1018306Medicaid