Provider Demographics
NPI:1336492297
Name:ELEVATE PHYSICAL THERAPY & PAIN CENTER INC
Entity Type:Organization
Organization Name:ELEVATE PHYSICAL THERAPY & PAIN CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:HERBERT
Authorized Official - Last Name:BLAKELY
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, OCS
Authorized Official - Phone:828-342-7358
Mailing Address - Street 1:4 MARKET ST STE 4103
Mailing Address - Street 2:
Mailing Address - City:BREVARD
Mailing Address - State:NC
Mailing Address - Zip Code:28712-5636
Mailing Address - Country:US
Mailing Address - Phone:828-342-7358
Mailing Address - Fax:
Practice Address - Street 1:4 MARKET ST
Practice Address - Street 2:SUITE 4103
Practice Address - City:BREVARD
Practice Address - State:NC
Practice Address - Zip Code:28712-5635
Practice Address - Country:US
Practice Address - Phone:828-877-2110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-16
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7217225100000X
NC8721225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC078RGOtherBLUE CROSS BLUE SHIELD
NC078RCOtherBLUE CROSS BLUE SHIELD
NC7211277Medicaid
NCB8364OtherMEDCOST
NCB8363OtherMEDCOST
NC7211281Medicaid
NCB8364OtherMEDCOST
NC7211281Medicaid