Healthcare Provider Details

I. General information

NPI: 1073523981
Provider Name (Legal Business Name): HEAVENLY FIT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 03/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 SKYHAWK AVE
CAMPBELLSPORT WI
53010-3055
US

IV. Provider business mailing address

545 SKYHAWK AVE
CAMPBELLSPORT WI
53010-3055
US

V. Phone/Fax

Practice location:
  • Phone: 920-533-3050
  • Fax: 920-533-3052
Mailing address:
  • Phone: 920-533-3050
  • Fax: 920-533-3052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY SCOTT MC CALLUM
Title or Position: OWNER
Credential:
Phone: 920-533-3050