Provider Demographics
NPI:1659036382
Name:CUSTOM FIT PHYSICAL THERAPY & WELLNESS
Entity Type:Organization
Organization Name:CUSTOM FIT PHYSICAL THERAPY & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAZIER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:207-590-6312
Mailing Address - Street 1:99 HARVARD ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04210-5232
Mailing Address - Country:US
Mailing Address - Phone:207-590-6312
Mailing Address - Fax:
Practice Address - Street 1:10 W BATES ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-6270
Practice Address - Country:US
Practice Address - Phone:207-590-6312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-08
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1699922955Medicaid