NPIMap

Organization Active NPI

Elite Performance and Rehab, LLC

  • Physical Therapy Clinic/Center
  • Vicksburg, MS
National Provider Identifier
1255877346
Registry record updated Jul 18, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical Therapy Clinic/CenterTaxonomy code 261QP2000X
Legal business name
ELITE PERFORMANCE AND REHAB, LLC
Practice address
1901 A Mission 66
Vicksburg, MS 39180
Phone
(601) 636-0097
NPI assigned
Jan 12, 2017
Last updated
Jul 18, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 18, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
William Fulcher Jr.
Title
Partner
Phone
(601) 636-0097

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physical Therapy Clinic/Center 261QP2000X NU Primary

Addresses

Primary practice location

1901 A Mission 66
Vicksburg, MS 39180

Mailing address

1901 A Mission 66
Vicksburg, MS 39180
Phone (601) 636-0097

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20170210000624 MS Part B Supplier - Physical/Occupational Therapy Group in Private Practice 8729361076 Receives reassigned benefits from 11 practitioners
Practice locations: Vicksburg, MS

National Provider Directory

National Provider Directory

Locations

2080 S Frontage Rd
Ste 108
Vicksburg, MS 39180
Phone (601) 629-4304

Practitioners & affiliated clinicians

Practitioners 15

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 15

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1484179200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658102400000",
    "number": "1255877346",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1901 A MISSION 66",
            "city": "VICKSBURG",
            "state": "MS",
            "postal_code": "39180",
            "telephone_number": "601-636-0097"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1901 A MISSION 66",
            "city": "VICKSBURG",
            "state": "MS",
            "postal_code": "39180",
            "telephone_number": "601-636-0097"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ELITE PERFORMANCE AND REHAB, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-01-12",
        "last_updated": "2022-07-18",
        "certification_date": "2022-07-18",
        "status": "A",
        "authorized_official_last_name": "FULCHER",
        "authorized_official_first_name": "WILLIAM",
        "authorized_official_title_or_position": "PARTNER",
        "authorized_official_telephone_number": "601-636-0097",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "261QP2000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Physical Therapy",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Vicksburg, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 18, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.