Provider Demographics
NPI:1316982523
Name:ELAM SPORTS, INC
Entity type:Organization
Organization Name:ELAM SPORTS, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COMPANY OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CHANDRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ELAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-382-1372
Mailing Address - Street 1:PO BOX 701119
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96709-1119
Mailing Address - Country:US
Mailing Address - Phone:808-674-9595
Mailing Address - Fax:808-674-9696
Practice Address - Street 1:91-1027 SHANGRILA ST BLDG 1867
Practice Address - Street 2:
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-2101
Practice Address - Country:US
Practice Address - Phone:808-674-9595
Practice Address - Fax:808-674-9696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI00A0218931OtherHMSA
HI50320201Medicaid