1336923697 NPI number — BEACH COWBOY FITNESS FOUNDATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336923697 NPI number — BEACH COWBOY FITNESS FOUNDATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEACH COWBOY FITNESS FOUNDATION
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:
1336923697
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1625
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT PLEASANT
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29465-1625
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-438-4833
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 QUEENSBOROUGH BLVD STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT PLEASANT
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29464-3191
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-438-4833
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/18/2023

Additional Information

Authorized Official

Authorized Official Last Name:
LETT
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
WEIN
Authorized Official Title or Position:
EXECUTIVE DIRECTOR CEO
Authorized Official Telephone Number:
843-438-4833

Provider Taxonomy Codes

  • Taxonomy code: 225800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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