Provider Demographics
NPI:1174699045
Name:ELITE SPORTS MEDICINE & PHYSICAL THERAPY LC
Entity type:Organization
Organization Name:ELITE SPORTS MEDICINE & PHYSICAL THERAPY LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BIAGIO
Authorized Official - Middle Name:D
Authorized Official - Last Name:MAZZA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:913-888-0014
Mailing Address - Street 1:12728 STATE LINE RD
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66209-1619
Mailing Address - Country:US
Mailing Address - Phone:913-888-0014
Mailing Address - Fax:816-941-2520
Practice Address - Street 1:12728 STATE LINE ROAD
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66209-1919
Practice Address - Country:US
Practice Address - Phone:913-888-0014
Practice Address - Fax:816-941-2520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT770000Medicare PIN