Provider Demographics
NPI:1316303134
Name:ELITE PHYSIO CONCEPTS
Entity type:Organization
Organization Name:ELITE PHYSIO CONCEPTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HENKELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:4079-249-6332
Mailing Address - Street 1:30 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-6201
Mailing Address - Country:US
Mailing Address - Phone:407-792-0031
Mailing Address - Fax:407-241-4992
Practice Address - Street 1:30 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-2122
Practice Address - Country:US
Practice Address - Phone:407-792-0031
Practice Address - Fax:407-241-4992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-08
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL00099412251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty