Provider Demographics
NPI:1508229782
Name:ELITE THERAPY AND WELLNESS CENTER, INC.
Entity Type:Organization
Organization Name:ELITE THERAPY AND WELLNESS CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WELDON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:719-543-2700
Mailing Address - Street 1:3715 THATCHER AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-1255
Mailing Address - Country:US
Mailing Address - Phone:719-470-2281
Mailing Address - Fax:719-301-7218
Practice Address - Street 1:3715 THATCHER AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-1255
Practice Address - Country:US
Practice Address - Phone:719-470-2281
Practice Address - Fax:719-301-7218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-04
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000197949Medicaid