Provider Demographics
NPI:1417311028
Name:ELATA HEALTH AND WELLNESS, LLC
Entity Type:Organization
Organization Name:ELATA HEALTH AND WELLNESS, LLC
Other - Org Name:ACTIVE LIFE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA CATHERINE
Authorized Official - Middle Name:YAZON
Authorized Official - Last Name:CUSTODIO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:972-984-7670
Mailing Address - Street 1:2600 ELDORADO PKWY STE 130
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75070-7517
Mailing Address - Country:US
Mailing Address - Phone:972-984-7670
Mailing Address - Fax:972-984-7671
Practice Address - Street 1:2600 ELDORADO PKWY STE 130
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75070-7517
Practice Address - Country:US
Practice Address - Phone:972-984-7670
Practice Address - Fax:972-984-7671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-09
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty