Provider Demographics
NPI:1932823200
Name:ELITE ONE ATHLETE LLC
Entity Type:Organization
Organization Name:ELITE ONE ATHLETE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF PHYSICAL THERAPY, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BENOIT
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:651-353-3708
Mailing Address - Street 1:6225 W BLACKHAWK DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6795
Mailing Address - Country:US
Mailing Address - Phone:651-353-3708
Mailing Address - Fax:
Practice Address - Street 1:6225 W BLACKHAWK DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6795
Practice Address - Country:US
Practice Address - Phone:651-353-3708
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-30
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy