Healthcare Provider Details

I. General information

NPI: 1679761696
Provider Name (Legal Business Name): FITNESS QUEST-PORT CHARLOTTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2007
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1649 TAMIAMI TRL STE 1A
PORT CHARLOTTE FL
33948-1019
US

IV. Provider business mailing address

3657 CORTEZ RD W STE 110
BRADENTON FL
34210-3171
US

V. Phone/Fax

Practice location:
  • Phone: 941-743-6700
  • Fax: 941-743-6707
Mailing address:
  • Phone: 941-743-6700
  • Fax: 941-743-6707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. MACKENZIE M BARTRUFF
Title or Position: COO
Credential:
Phone: 941-743-6700