Provider Demographics
NPI:1932686904
Name:ELITE BEHAVIORAL MEDICINE LLC
Entity Type:Organization
Organization Name:ELITE BEHAVIORAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOYD
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:770-910-2279
Mailing Address - Street 1:1800 HOG MOUNTAIN RD
Mailing Address - Street 2:BLDG 100, STE 103
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677
Mailing Address - Country:US
Mailing Address - Phone:706-410-1033
Mailing Address - Fax:
Practice Address - Street 1:1800 HOG MOUNTAIN RD
Practice Address - Street 2:BLDG 100, STE 103
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677
Practice Address - Country:US
Practice Address - Phone:770-910-2279
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-23
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA20292261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center