Provider Demographics
NPI:1083434674
Name:ELITE PHYSICAL THERAPY AND WELLNESS
Entity type:Organization
Organization Name:ELITE PHYSICAL THERAPY AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:POND
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:801-735-6759
Mailing Address - Street 1:55 E 100 N STE 201B
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-4648
Mailing Address - Country:US
Mailing Address - Phone:385-595-8892
Mailing Address - Fax:
Practice Address - Street 1:55 E 100 N STE 201B
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-4648
Practice Address - Country:US
Practice Address - Phone:385-595-8892
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-16
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy