Provider Demographics
NPI:1871963025
Name:ELITE PHYSICAL MEDICINE
Entity type:Organization
Organization Name:ELITE PHYSICAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHYSICAL MEDICINE
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:972-339-2464
Mailing Address - Street 1:2535 TYE LN
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75056-3936
Mailing Address - Country:US
Mailing Address - Phone:972-339-2464
Mailing Address - Fax:
Practice Address - Street 1:2711 N HASKELL AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-2911
Practice Address - Country:US
Practice Address - Phone:972-885-0440
Practice Address - Fax:888-317-7686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12049111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX329459YQ2YMedicare PIN