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General NPI Number Information
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NPI Number | 1902217896
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Entity Type | Organization
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Legal Business Name | CUSTOM FITNESS LLC
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Dates
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Enumeration Date | 05/13/2014
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Last Update Date | 05/13/2014
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Provider Practice Location Address
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Address Line | 588 WEST MARINE CORPS DR STE 101
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City | HAGATNA
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State | GU
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Zip | 96910
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Country | US
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Telephone | 671-989-0436
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 7372
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City | TAMUNING
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State | GU
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Zip | 96931-7372
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | SAMANTHA SABLAN
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Credential |
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Telephone | 671-989-0436
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | PT-106
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License Number State | GU
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