Provider Demographics
NPI:1932356870
Name:ELEVATION PHYSICAL THERAPY AND SPORTS AND REHABILITATION, LLC
Entity type:Organization
Organization Name:ELEVATION PHYSICAL THERAPY AND SPORTS AND REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DUDLEY
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:702-768-8050
Mailing Address - Street 1:10245 S MARYLAND PKWY UNIT 153
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89183-4041
Mailing Address - Country:US
Mailing Address - Phone:702-768-8050
Mailing Address - Fax:702-731-2565
Practice Address - Street 1:10245 S MARYLAND PKWY 153
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89183
Practice Address - Country:US
Practice Address - Phone:702-768-8050
Practice Address - Fax:702-731-2565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-22
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1007638532251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health