Provider Demographics
NPI:1821256298
Name:ELITE PHYSICAL THERAPY GROUP, LLC
Entity Type:Organization
Organization Name:ELITE PHYSICAL THERAPY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/CLINIC OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:PETTINGILL
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:253-732-8116
Mailing Address - Street 1:21707 103RD AVENUE CT E STE B202
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98338-8308
Mailing Address - Country:US
Mailing Address - Phone:253-271-7339
Mailing Address - Fax:253-655-5845
Practice Address - Street 1:223 140TH ST S STE 700
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98444-4549
Practice Address - Country:US
Practice Address - Phone:253-531-5645
Practice Address - Fax:253-536-3467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602832882261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
G8876026OtherMEDICARE PTAN #
WA2001745Medicaid