Provider Demographics
NPI:1144504754
Name:FITNESS DESIGNS PHYSICAL THERAPY AND SPORTS REHAB LLC
Entity type:Organization
Organization Name:FITNESS DESIGNS PHYSICAL THERAPY AND SPORTS REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:PIFER
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:618-656-1122
Mailing Address - Street 1:16 GINGER CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-3502
Mailing Address - Country:US
Mailing Address - Phone:618-656-1122
Mailing Address - Fax:618-656-1171
Practice Address - Street 1:16 GINGER CREEK PKWY
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-3502
Practice Address - Country:US
Practice Address - Phone:618-656-1122
Practice Address - Fax:618-656-1171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-30
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070006305225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL703470Medicare PIN