MEDICARE: FITNESS FORMULA, LTD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1033596440
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FITNESS FORMULA, LTD

Provider Business Mailing Address
First Line	:	619 W JACKSON BLVD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60661-5606
Country	:	US
Telephone Number	:	312-648-4666
Fax Number	:	312-648-0155

Provider Business Practice Location Address
First Line	:	619 W JACKSON BLVD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60661-5606
Country	:	US
Telephone Number	:	312-648-4666
Fax Number	:	312-648-0155

Authorized Official
Title or Position	:	CFO
Name	:	BRIAN SINGLETON
Credential	:
Telephone Number	:	312-648-4666

Provider Enumeration Date	:	05/05/2015
Last Update Date	:	05/05/2015

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