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General NPI Number Information
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NPI Number | 1194029132
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Entity Type | Organization
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Legal Business Name | THE FIT MED EXPERIENCE
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Dates
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Enumeration Date | 01/05/2011
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Last Update Date | 01/05/2011
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Provider Practice Location Address
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Address Line | 6392 LINDEN RD
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City | ROCKFORD
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State | IL
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Zip | 61109-2816
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Country | US
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Telephone | 815-540-8368
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Fax |
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Provider Business Mailing Address
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Address Line | 5411 E STATE ST
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City | ROCKFORD
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State | IL
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Zip | 61108-2907
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Country | US
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Telephone | 815-540-8368
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Fax |
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Authorized Official
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Title or Position | LICENSED MEDICAL MASSAGE THERAPIST
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Name | MR. CHRISTOPHER SCOTT MILLS
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Credential | BS, CSCS, LMT
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Telephone | 815-540-8368
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 227003757
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License Number State | IL
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