Provider Demographics
NPI:1710505847
Name:ELITE SPORT THERAPY & WELLNESS
Entity type:Organization
Organization Name:ELITE SPORT THERAPY & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUNIL
Authorized Official - Middle Name:
Authorized Official - Last Name:PULLUKAT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-748-8804
Mailing Address - Street 1:495 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-3044
Mailing Address - Country:US
Mailing Address - Phone:847-748-8804
Mailing Address - Fax:847-495-2162
Practice Address - Street 1:495 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-3044
Practice Address - Country:US
Practice Address - Phone:847-748-8804
Practice Address - Fax:847-495-2162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-06
Last Update Date:2025-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL12469650OtherCAQH