Provider Demographics
NPI:1558958009
Name:GEORGETOWN FITNESS INC
Entity Type:Organization
Organization Name:GEORGETOWN FITNESS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:607-280-3441
Mailing Address - Street 1:5225 SHERIDAN DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-3573
Mailing Address - Country:US
Mailing Address - Phone:607-280-3441
Mailing Address - Fax:
Practice Address - Street 1:5225 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-3573
Practice Address - Country:US
Practice Address - Phone:716-580-3362
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-30
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Single Specialty
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight ManagementGroup - Single Specialty
No133VN1301XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, OncologyGroup - Single Specialty
No133VN1501XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Sports DieteticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY010418-01OtherNY STATE CERTIFICATION