Provider Demographics
NPI:1649436700
Name:SUMMIT FITNESS & REHABILITATION, LLC
Entity type:Organization
Organization Name:SUMMIT FITNESS & REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GRANGER
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:203-546-8648
Mailing Address - Street 1:195 FEDERAL RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:BROOKFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06804-2556
Mailing Address - Country:US
Mailing Address - Phone:203-546-8648
Mailing Address - Fax:
Practice Address - Street 1:195 FEDERAL RD
Practice Address - Street 2:SUITE 6
Practice Address - City:BROOKFIELD
Practice Address - State:CT
Practice Address - Zip Code:06804-2556
Practice Address - Country:US
Practice Address - Phone:203-546-8648
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-29
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008174261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT020621971OtherTRICARE NORTH ID
CT650001492Medicare PIN
CTD100000161Medicare PIN