MEDICARE: OMNIFIT SPORTS & FITNESS LLC

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	305R00000X	Preferred Provider Organization

General Provider Information

NPI Number	:	1720685563
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMNIFIT SPORTS & FITNESS LLC

Provider Business Mailing Address
First Line	:	1838 NW 57TH ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33142-3056
Country	:	US
Telephone Number	:	786-525-7669
Fax Number	:

Provider Business Practice Location Address
First Line	:	1838 NW 57TH ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33142-3056
Country	:	US
Telephone Number	:	786-525-7669
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DERRICK SPENCE JR.
Credential	:
Telephone Number	:	786-371-4116

Provider Enumeration Date	:	10/05/2020
Last Update Date	:	10/05/2020

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Directions to “OMNIFIT SPORTS & FITNESS LLC ” Practice Location

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