Provider Demographics
NPI:1780702209
Name:ELITE PHYSICAL THERAPY AND WELLNESS, INC.
Entity type:Organization
Organization Name:ELITE PHYSICAL THERAPY AND WELLNESS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER / FOUNDER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:DIMEGLIO
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L, HTC
Authorized Official - Phone:951-200-3620
Mailing Address - Street 1:24630 WASHINGTON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-6177
Mailing Address - Country:US
Mailing Address - Phone:951-200-3620
Mailing Address - Fax:951-200-5811
Practice Address - Street 1:79440 CORPORATE CENTER DR STE 112
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-7243
Practice Address - Country:US
Practice Address - Phone:760-771-9054
Practice Address - Fax:760-771-9057
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALL STAR PHYSICAL THERAPY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-26
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
CA282842251S0007X, 2251X0800X
CA065005225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT282840Medicare ID - Type Unspecified
CAP90837Medicare UPIN