Provider Demographics
NPI:1669963021
Name:ELITE PHYSICAL MEDICINE AND REHABILITATION LLC
Entity type:Organization
Organization Name:ELITE PHYSICAL MEDICINE AND REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SEGRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-486-3744
Mailing Address - Street 1:6213 SNIDER RD STE A
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-2643
Mailing Address - Country:US
Mailing Address - Phone:513-486-3744
Mailing Address - Fax:
Practice Address - Street 1:6213 SNIDER RD STE A
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-2793
Practice Address - Country:US
Practice Address - Phone:513-486-3744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-22
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty