MEDICARE: K AND L FITNESS, INC.

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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1285745968
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	K AND L FITNESS, INC.

Provider Business Mailing Address
First Line	:	3576 SAINT JOHNS AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32205-8446
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3576 SAINT JOHNS AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32205-8446
Country	:	US
Telephone Number	:	904-421-2119
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	LYNN PETERSON
Credential	:
Telephone Number	:	904-387-9355

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/25/2007

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