MEDICARE: FIT FOR LIFE REHAB AND FITNESS CLINIC, 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	261QP2000X	Physical Therapy Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	04922970	OTHER	IL	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1417179979
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIT FOR LIFE REHAB AND FITNESS CLINIC, INC.

Provider Business Mailing Address
First Line	:	655 ROCKLAND RD
Second Line	:	SUITE 101
City	:	LAKE BLUFF
State	:	IL
Zip	:	60044-1782
Country	:	US
Telephone Number	:	847-234-4847
Fax Number	:

Provider Business Practice Location Address
First Line	:	655 ROCKLAND RD
Second Line	:	SUITE 101
City	:	LAKE BLUFF
State	:	IL
Zip	:	60044-1782
Country	:	US
Telephone Number	:	847-234-4847
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SUSAN E DUTTGE
Credential	:
Telephone Number	:	847-234-4847

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	11/18/2009

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