Provider Demographics
NPI:1972011443
Name:MEDICAL FITNESS CENTER LLC
Entity Type:Organization
Organization Name:MEDICAL FITNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHATTO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-870-3350
Mailing Address - Street 1:2315 E CONNER ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-3681
Mailing Address - Country:US
Mailing Address - Phone:208-870-3350
Mailing Address - Fax:
Practice Address - Street 1:1396 E IRON EAGLE DR STE 100
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6620
Practice Address - Country:US
Practice Address - Phone:208-870-3350
Practice Address - Fax:208-870-3350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-17
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1883225100000X
225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty