Provider Demographics
NPI:1194029132
Name:THE FIT MED EXPERIENCE
Entity Type:Organization
Organization Name:THE FIT MED EXPERIENCE
Other - Org Name:FIT MED
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSED MEDICAL MASSAGE THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:BS, CSCS, LMT
Authorized Official - Phone:815-540-8368
Mailing Address - Street 1:5411 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2907
Mailing Address - Country:US
Mailing Address - Phone:815-540-8368
Mailing Address - Fax:
Practice Address - Street 1:6392 LINDEN RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61109-2816
Practice Address - Country:US
Practice Address - Phone:815-540-8368
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227003757225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty