Provider Demographics
NPI:1366805848
Name:SUMMERVILLE FITNESS LLC
Entity type:Organization
Organization Name:SUMMERVILLE FITNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:NICHOLE
Authorized Official - Last Name:SUMMERVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:716-472-0652
Mailing Address - Street 1:25 WORTHINGTON LN
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:NY
Mailing Address - Zip Code:14086-9391
Mailing Address - Country:US
Mailing Address - Phone:716-472-0652
Mailing Address - Fax:
Practice Address - Street 1:1900 RIDGE RD STE 127
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-3332
Practice Address - Country:US
Practice Address - Phone:716-677-2969
Practice Address - Fax:716-674-2969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-01
Last Update Date:2016-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015127-1261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy