Provider Demographics
NPI:1639698269
Name:ELITE SPINE LLC
Entity Type:Organization
Organization Name:ELITE SPINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NAKAYAMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-872-2929
Mailing Address - Street 1:800 DUNLAWTON AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-4249
Mailing Address - Country:US
Mailing Address - Phone:386-265-0102
Mailing Address - Fax:386-401-2316
Practice Address - Street 1:800 DUNLAWTON AVE STE 103
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4249
Practice Address - Country:US
Practice Address - Phone:386-265-0102
Practice Address - Fax:386-401-2316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-14
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH12049261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1295271344Medicaid