Provider Demographics
NPI:1235180811
Name:ELITE PHYSICAL THERAPY AND SPORTS
Entity Type:Organization
Organization Name:ELITE PHYSICAL THERAPY AND SPORTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:STACK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:808-572-7790
Mailing Address - Street 1:1043 MAKAWAO AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:MAKAWAO
Mailing Address - State:HI
Mailing Address - Zip Code:96768-9465
Mailing Address - Country:US
Mailing Address - Phone:808-572-7790
Mailing Address - Fax:808-573-4721
Practice Address - Street 1:1043 MAKAWAO AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:MAKAWAO
Practice Address - State:HI
Practice Address - Zip Code:96768-9465
Practice Address - Country:US
Practice Address - Phone:808-572-7790
Practice Address - Fax:808-573-4721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIW6201699001225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI101246Medicare ID - Type Unspecified