1114097193 NPI number — FIT FOR LIFE HEALTH SERVICES PA

Table of content: (NPI 1114097193)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114097193 NPI number — FIT FOR LIFE HEALTH SERVICES PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIT FOR LIFE HEALTH SERVICES PA
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:
1114097193
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2960 IMMOKALEE RD
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
NAPLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34110-1439
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-513-9800
Provider Business Mailing Address Fax Number:
239-513-0043

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2960 IMMOKALEE RD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
NAPLES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34110-1439
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-513-9800
Provider Business Practice Location Address Fax Number:
239-513-0043
Provider Enumeration Date:
11/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SEEKINS
Authorized Official First Name:
SUZANNE
Authorized Official Middle Name:
AMANDA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
239-513-9800

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH 7341 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6312490 . This is a "CIGNA ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: K0166 . This is a "MEDICARE GROUP ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 55621 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 018314800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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