Provider Demographics
NPI:1881345684
Name:SPECIALLY FIT FOUNDATION
Entity type:Organization
Organization Name:SPECIALLY FIT FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED ALF ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:STEPHAN
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-389-9474
Mailing Address - Street 1:11118 LAKESIDE VISTA DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-2919
Mailing Address - Country:US
Mailing Address - Phone:727-831-2829
Mailing Address - Fax:888-814-0945
Practice Address - Street 1:2224 ARCH MCDONALD DR
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:FL
Practice Address - Zip Code:33527-6342
Practice Address - Country:US
Practice Address - Phone:727-831-2829
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility