Provider Demographics
NPI:1205803558
Name:FITNESS FORUM SERVICES LLC
Entity type:Organization
Organization Name:FITNESS FORUM SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-477-0888
Mailing Address - Street 1:322 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:WEST BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02379-1824
Mailing Address - Country:US
Mailing Address - Phone:508-559-0993
Mailing Address - Fax:
Practice Address - Street 1:110 LIBERTY ST
Practice Address - Street 2:SUITE 1300
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5521
Practice Address - Country:US
Practice Address - Phone:508-580-0144
Practice Address - Fax:508-580-0449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA623323OtherHARVARD PILGRIM HEALTHCARE
MA613818OtherTUFTS
MA9786384Medicaid
MA226531Medicare ID - Type Unspecified