Provider Demographics
NPI:1063612067
Name:FORM & FITNESS
Entity type:Organization
Organization Name:FORM & FITNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:QUIST
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:262-241-3449
Mailing Address - Street 1:11053 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5032
Mailing Address - Country:US
Mailing Address - Phone:262-241-3449
Mailing Address - Fax:262-241-5229
Practice Address - Street 1:11053 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5032
Practice Address - Country:US
Practice Address - Phone:262-241-3449
Practice Address - Fax:262-241-5229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty