Provider Demographics
NPI:1235478991
Name:ELITE PHYSICAL MEDICINE
Entity Type:Organization
Organization Name:ELITE PHYSICAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:O
Authorized Official - Last Name:MILAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:714-731-9355
Mailing Address - Street 1:217 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3603
Mailing Address - Country:US
Mailing Address - Phone:714-731-9355
Mailing Address - Fax:714-544-1538
Practice Address - Street 1:217 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3603
Practice Address - Country:US
Practice Address - Phone:714-731-9355
Practice Address - Fax:714-544-1538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-31
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA111NR0400X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty