Provider Demographics
NPI:1538409065
Name:ELITE PERFORMANCE PHYSICAL THERAPY, INC.
Entity type:Organization
Organization Name:ELITE PERFORMANCE PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:KOZUKI
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:949-467-9656
Mailing Address - Street 1:2900 BRISTOL ST
Mailing Address - Street 2:BUILDING G, SUITE 102
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-5981
Mailing Address - Country:US
Mailing Address - Phone:949-467-9656
Mailing Address - Fax:949-266-5629
Practice Address - Street 1:2900 BRISTOL ST
Practice Address - Street 2:BUILDING G, SUITE 102
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5981
Practice Address - Country:US
Practice Address - Phone:949-467-9656
Practice Address - Fax:949-266-5629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-20
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty