Provider Demographics
NPI:1669736120
Name:ELITE HEALTHCARE PHYSICAL MEDICINE
Entity type:Organization
Organization Name:ELITE HEALTHCARE PHYSICAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-214-9146
Mailing Address - Street 1:307 ADAMSON SQ
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3213
Mailing Address - Country:US
Mailing Address - Phone:770-214-9146
Mailing Address - Fax:770-214-9166
Practice Address - Street 1:307 ADAMSON SQ
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3213
Practice Address - Country:US
Practice Address - Phone:770-214-9146
Practice Address - Fax:770-214-9166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-29
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007565111NR0400X
GARN148627363LF0000X
GA052922208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty