Provider Demographics
NPI:1720139207
Name:ADVANTAGE HEALTH AND FITNESS
Entity Type:Organization
Organization Name:ADVANTAGE HEALTH AND FITNESS
Other - Org Name:FITNESS ADVANTAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KELVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUENSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-396-0309
Mailing Address - Street 1:1249 S DIAMOND BAR BLVD # 112
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-4122
Mailing Address - Country:US
Mailing Address - Phone:909-396-0309
Mailing Address - Fax:909-396-0619
Practice Address - Street 1:1200 S DIAMOND BAR BLVD
Practice Address - Street 2:SUITE#108
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-2298
Practice Address - Country:US
Practice Address - Phone:909-396-0309
Practice Address - Fax:909-396-0619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherEIN NUMBER