Provider Demographics
NPI:1497027775
Name:FITNESS CLINIC
Entity Type:Organization
Organization Name:FITNESS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BROADWATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-983-7494
Mailing Address - Street 1:2219 GREENWAY DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-3202
Mailing Address - Country:US
Mailing Address - Phone:601-983-7494
Mailing Address - Fax:601-371-3993
Practice Address - Street 1:2219 GREENWAY DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3202
Practice Address - Country:US
Practice Address - Phone:601-983-7494
Practice Address - Fax:601-371-3993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-02
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty