Provider Demographics
NPI:1104095611
Name:ELITE SPORTS MEDICINE LLC
Entity type:Organization
Organization Name:ELITE SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GIAMBRONE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:775-786-5333
Mailing Address - Street 1:1875 PLUMAS ST
Mailing Address - Street 2:STE 6A
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-3321
Mailing Address - Country:US
Mailing Address - Phone:775-786-5333
Mailing Address - Fax:775-786-5336
Practice Address - Street 1:1875 PLUMAS ST
Practice Address - Street 2:STE 6A
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-3387
Practice Address - Country:US
Practice Address - Phone:775-786-5333
Practice Address - Fax:775-786-5336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2060213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1861413445OtherINDIVIDUAL NPI
NVV38763Medicare PIN