Provider Demographics
NPI:1891488433
Name:ELITE PROFESSIONAL PROVIDERS, LLC
Entity Type:Organization
Organization Name:ELITE PROFESSIONAL PROVIDERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-220-4482
Mailing Address - Street 1:2135 E INDEPENDENCE ST # 1093
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-3749
Mailing Address - Country:US
Mailing Address - Phone:417-220-4482
Mailing Address - Fax:417-414-0017
Practice Address - Street 1:3322 S CAMPBELL AVE STE T-1
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-4980
Practice Address - Country:US
Practice Address - Phone:417-220-4482
Practice Address - Fax:417-414-0017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-30
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500128969Medicaid