1205803558 NPI number — FITNESS FORUM SERVICES LLC

Table of content: (NPI 1205803558)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205803558 NPI number — FITNESS FORUM SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FITNESS FORUM SERVICES 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:
1205803558
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
322 E CENTER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST BRIDGEWATER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02379-1824
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-559-0993
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 LIBERTY ST
Provider Second Line Business Practice Location Address:
SUITE 1300
Provider Business Practice Location Address City Name:
BROCKTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02301-5521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-580-0144
Provider Business Practice Location Address Fax Number:
508-580-0449
Provider Enumeration Date:
03/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
315-477-0888

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 623323 . This is a "HARVARD PILGRIM HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 613818 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9786384 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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