Provider Demographics
NPI:1336590835
Name:ELITE REHAB PHYSICAL THERAPY
Entity type:Organization
Organization Name:ELITE REHAB PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:STILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:435-781-1502
Mailing Address - Street 1:425 S VERNAL AVE
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-3237
Mailing Address - Country:US
Mailing Address - Phone:435-781-1502
Mailing Address - Fax:435-781-1505
Practice Address - Street 1:425 S VERNAL AVE
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-3237
Practice Address - Country:US
Practice Address - Phone:435-781-1502
Practice Address - Fax:435-781-1505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT72980272401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty