Provider Demographics
NPI:1417179979
Name:FIT FOR LIFE REHAB AND FITNESS CLINIC, INC.
Entity Type:Organization
Organization Name:FIT FOR LIFE REHAB AND FITNESS CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:DUTTGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-234-4847
Mailing Address - Street 1:655 ROCKLAND RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAKE BLUFF
Mailing Address - State:IL
Mailing Address - Zip Code:60044-1782
Mailing Address - Country:US
Mailing Address - Phone:847-234-4847
Mailing Address - Fax:
Practice Address - Street 1:655 ROCKLAND RD
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKE BLUFF
Practice Address - State:IL
Practice Address - Zip Code:60044-1782
Practice Address - Country:US
Practice Address - Phone:847-234-4847
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04922970OtherBCBS PROVIDER NUMBER