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General NPI Number Information
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NPI Number | 1609647122
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Entity Type | Organization
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Legal Business Name | CUSTOM FIT WELLNESS
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Dates
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Enumeration Date | 01/12/2024
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Last Update Date | 01/12/2024
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Provider Practice Location Address
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Address Line | 1808 MIDDLE COUNTRY RD
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City | RIDGE
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State | NY
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Zip | 11961-2406
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Country | US
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Telephone | 516-946-9417
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Fax |
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Provider Business Mailing Address
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Address Line | 458 RANDALL RD
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City | RIDGE
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State | NY
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Zip | 11961-2102
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Country | US
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Telephone | 516-946-9417
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SUSAN YEOMAN
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Credential | LMT
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Telephone | 516-946-9417
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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