Provider Demographics
NPI:1073523981
Name:HEAVENLY FIT LLC
Entity Type:Organization
Organization Name:HEAVENLY FIT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:MC CALLUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-533-3050
Mailing Address - Street 1:545 SKYHAWK AVE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSPORT
Mailing Address - State:WI
Mailing Address - Zip Code:53010-3055
Mailing Address - Country:US
Mailing Address - Phone:920-533-3050
Mailing Address - Fax:920-533-3052
Practice Address - Street 1:545 SKYHAWK AVE
Practice Address - Street 2:
Practice Address - City:CAMPBELLSPORT
Practice Address - State:WI
Practice Address - Zip Code:53010-3055
Practice Address - Country:US
Practice Address - Phone:920-533-3050
Practice Address - Fax:920-533-3052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5099420001Medicare NSC