Provider Demographics
NPI:1912059700
Name:ELITE PHYSICAL THERAPY AND WELLNESS
Entity Type:Organization
Organization Name:ELITE PHYSICAL THERAPY AND WELLNESS
Other - Org Name:JACOB ELITE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:810-441-3033
Mailing Address - Street 1:4053 S LAPEER RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:METAMORA
Mailing Address - State:MI
Mailing Address - Zip Code:48455-8721
Mailing Address - Country:US
Mailing Address - Phone:810-678-3202
Mailing Address - Fax:
Practice Address - Street 1:4053 S LAPEER RD
Practice Address - Street 2:SUITE C
Practice Address - City:METAMORA
Practice Address - State:MI
Practice Address - Zip Code:48455-8721
Practice Address - Country:US
Practice Address - Phone:810-678-3202
Practice Address - Fax:810-678-3205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011436261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy