Provider Demographics
NPI:1225280597
Name:THE MAINE FITNESS STORE, INC
Entity Type:Organization
Organization Name:THE MAINE FITNESS STORE, INC
Other - Org Name:MAINE FITNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:N
Authorized Official - Last Name:LEACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-990-4552
Mailing Address - Street 1:849 STILLWATER AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3624
Mailing Address - Country:US
Mailing Address - Phone:207-990-4552
Mailing Address - Fax:
Practice Address - Street 1:849 STILLWATER AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3624
Practice Address - Country:US
Practice Address - Phone:207-990-4552
Practice Address - Fax:207-990-4552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-18
Last Update Date:2008-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME03103032OtherMEMIC