Provider Demographics
NPI:1508140500
Name:INTERSPORT FITNESS CENTER
Entity Type:Organization
Organization Name:INTERSPORT FITNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:GARCIA
Authorized Official - Last Name:LAUGHLIN
Authorized Official - Suffix:
Authorized Official - Credentials:CPT
Authorized Official - Phone:209-480-9309
Mailing Address - Street 1:4847 STRATOS WAY
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9544
Mailing Address - Country:US
Mailing Address - Phone:209-522-9309
Mailing Address - Fax:209-522-9365
Practice Address - Street 1:4847 STRATOS WAY
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-9544
Practice Address - Country:US
Practice Address - Phone:209-522-9309
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-10
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA164631174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty