Provider Demographics
NPI:1609647122
Name:CUSTOM FIT WELLNESS
Entity Type:Organization
Organization Name:CUSTOM FIT WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:YEOMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:516-946-9417
Mailing Address - Street 1:458 RANDALL RD
Mailing Address - Street 2:
Mailing Address - City:RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:11961-2102
Mailing Address - Country:US
Mailing Address - Phone:516-946-9417
Mailing Address - Fax:
Practice Address - Street 1:1808 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:RIDGE
Practice Address - State:NY
Practice Address - Zip Code:11961-2406
Practice Address - Country:US
Practice Address - Phone:516-946-9417
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center