Provider Demographics
NPI:1538896022
Name:ELITE PHYSICAL THERAPY AND SPORTS MEDICINE LLC
Entity type:Organization
Organization Name:ELITE PHYSICAL THERAPY AND SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:BAISDEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:765-297-0975
Mailing Address - Street 1:823 PARK EAST BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-0811
Mailing Address - Country:US
Mailing Address - Phone:765-297-0975
Mailing Address - Fax:765-297-0974
Practice Address - Street 1:823 PARK EAST BLVD STE B
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-0811
Practice Address - Country:US
Practice Address - Phone:765-297-0975
Practice Address - Fax:765-297-0974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-04
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty