Provider Demographics
NPI:1528330792
Name:MEDI- ELITE, PC
Entity type:Organization
Organization Name:MEDI- ELITE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MAHALIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON-BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN
Authorized Official - Phone:214-277-2243
Mailing Address - Street 1:4621 S COOPER ST STE 131-717
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-5866
Mailing Address - Country:US
Mailing Address - Phone:214-277-2243
Mailing Address - Fax:214-231-2926
Practice Address - Street 1:2721 CENTRAL DR
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-4810
Practice Address - Country:US
Practice Address - Phone:682-703-8881
Practice Address - Fax:706-203-3259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-03
Last Update Date:2024-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP117597311ZA0620X, 314000000X, 363L00000X, 363LA2200X, 363LC1500X, 363LP2300X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care HomeGroup - Multi-Specialty
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing FacilityGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity HealthGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty