1528219631 NPI number — FITNESS QUEST - BRADENTON LLC

Table of content: (NPI 1528219631)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528219631 NPI number — FITNESS QUEST - BRADENTON LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FITNESS QUEST - BRADENTON LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528219631
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11045 TAMIAMI TRL S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH PORT
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34287-1072
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-474-2700
Provider Business Mailing Address Fax Number:
941-474-8081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2828 S MCCALL RD
Provider Second Line Business Practice Location Address:
UNIT 40
Provider Business Practice Location Address City Name:
ENGLEWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34224-7791
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-474-2700
Provider Business Practice Location Address Fax Number:
941-474-8081
Provider Enumeration Date:
10/07/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BARTRUFF
Authorized Official First Name:
MACKENZIE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
941-474-2700

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: BN795A . This is a "MEDICARE PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".