Provider Demographics
NPI:1942953724
Name:ELITE ORTHOSPORT PERFORMANCE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:ELITE ORTHOSPORT PERFORMANCE PHYSICAL THERAPY
Other - Org Name:ELITE ORTHOSPORT PERFORMANCE PHYSICAL THERAPY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:310-477-7774
Mailing Address - Street 1:12121 WILSHIRE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1221
Mailing Address - Country:US
Mailing Address - Phone:310-477-7774
Mailing Address - Fax:
Practice Address - Street 1:12121 WILSHIRE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1221
Practice Address - Country:US
Practice Address - Phone:310-477-7774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-01
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty