1427121607 NPI number — FITNESS REHAB LLC

Table of content: (NPI 1427121607)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427121607 NPI number — FITNESS REHAB LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FITNESS REHAB 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:
6
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:
1427121607
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/14/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 307
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOUNTIFUL
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84011-0307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-700-6907
Provider Business Mailing Address Fax Number:
801-294-6917

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3089 N CANYON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROVO
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84604-3920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-375-6500
Provider Business Practice Location Address Fax Number:
801-375-6505
Provider Enumeration Date:
11/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NACKOS
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
CHARLES
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
801-375-6500

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  5133156-2401 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 51331562400001 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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