Provider Application · Elite Cell Source

Account type

Tell us who is registering.

DoctorClinicClinic Staff

Your details

The person creating this account.

First name *

Last name *

Direct phone

Specialty

Your credentials

Used to verify your eligibility to order.

NPI number *

DEA number

State license number *

License state *

Expiration

Practice information

Your clinic or practice details.

Practice / clinic name *

Office address *

Suite / unit

City *

State *

ZIP *

Office phone *

Office email *

Primary contact person

Account credentials

You'll use these to sign in.

Email *

Password *

Confirm password *

License documentation

Optional now — we may request it during review.

Upload license (PDF, JPG, or PNG · max 15 MB)

Attestation

I confirm that the information provided is accurate, that I am a licensed provider (or authorized to register on behalf of one), and that I am authorized to place patient-specific prescription orders. I have read and agree to the Provider Terms and Privacy Policy.

Registration is free. Ordering access is enabled only after verification.