1356686943 NPI number — SHIP SHAPE WATER FITNESS SPECIALISTS, LLC

Table of content: (NPI 1356686943)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356686943 NPI number — SHIP SHAPE WATER FITNESS SPECIALISTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHIP SHAPE WATER FITNESS SPECIALISTS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356686943
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
47 KALAMAZOO TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM COAST
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32164-5633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-986-5655
Provider Business Mailing Address Fax Number:
386-313-1886

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
47 KALAMAZOO TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM COAST
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32164-5633
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-986-5655
Provider Business Practice Location Address Fax Number:
386-313-1886
Provider Enumeration Date:
12/07/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
SHARON
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
FITNESS TRAINER
Authorized Official Telephone Number:
386-986-5655

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X , with the licence number:  AFAA 32385 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251K00000X , with the licence number: AEA 60145 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)