MEDICARE: FITNESS FOCUS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center	4723	MN

General Provider Information

NPI Number	:	1720156680
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FITNESS FOCUS, INC.

Provider Business Mailing Address
First Line	:	688 WILDWOOD ROAD
Second Line	:
City	:	MAHTOMEDI
State	:	MN
Zip	:	55115-2060
Country	:	US
Telephone Number	:	651-429-9947
Fax Number	:	651-429-1029

Provider Business Practice Location Address
First Line	:	688 WILDWOOD ROAD
Second Line	:
City	:	MAHTOMEDI
State	:	MN
Zip	:	55115-2060
Country	:	US
Telephone Number	:	651-429-9947
Fax Number	:	651-429-1029

Authorized Official
Title or Position	:	OWNER - PHYSICAL THERAPIST
Name	:	MRS. SHANNON DEE MAIXNER
Credential	:	PT
Telephone Number	:	651-429-9947

Provider Enumeration Date	:	11/30/2006
Last Update Date	:	09/26/2022

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