Provider Demographics
NPI:1124666144
Name:ELITE FITNESS AND PHYSICAL THERAPY PLLC
Entity type:Organization
Organization Name:ELITE FITNESS AND PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TARRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WARDRUP STETSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, CSCS
Authorized Official - Phone:423-737-3363
Mailing Address - Street 1:2300 E LAS OLAS BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-1598
Mailing Address - Country:US
Mailing Address - Phone:423-737-3363
Mailing Address - Fax:
Practice Address - Street 1:2300 E LAS OLAS BLVD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-1598
Practice Address - Country:US
Practice Address - Phone:423-737-3363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-20
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty