Provider Demographics
NPI:1710109061
Name:FITNESS MADE FUN INC
Entity Type:Organization
Organization Name:FITNESS MADE FUN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JORDANA
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:FAINE SIADMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:954-661-5695
Mailing Address - Street 1:1634 POINSETTIA DR
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33305-3245
Mailing Address - Country:US
Mailing Address - Phone:954-661-5695
Mailing Address - Fax:954-568-0682
Practice Address - Street 1:1634 POINSETTIA DR
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33305-3245
Practice Address - Country:US
Practice Address - Phone:954-661-5695
Practice Address - Fax:954-568-0682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 19480251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891911900Medicaid