Provider Demographics
NPI:1982207437
Name:ELITE MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:ELITE MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-988-3839
Mailing Address - Street 1:114 CANAL ST STE 201
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-4260
Mailing Address - Country:US
Mailing Address - Phone:912-988-3839
Mailing Address - Fax:912-988-3839
Practice Address - Street 1:114 CANAL ST STE 201
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4260
Practice Address - Country:US
Practice Address - Phone:912-988-3839
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care