Provider Demographics
NPI:1578767299
Name:KIDZPLEX FITNESS
Entity Type:Organization
Organization Name:KIDZPLEX FITNESS
Other - Org Name:RUE DE SANTE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:LORRAINE
Authorized Official - Last Name:PINCKNEY
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN
Authorized Official - Phone:910-484-9212
Mailing Address - Street 1:4425 BENT GRASS DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28312-9140
Mailing Address - Country:US
Mailing Address - Phone:910-484-9212
Mailing Address - Fax:910-484-9212
Practice Address - Street 1:1830Q OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3421
Practice Address - Country:US
Practice Address - Phone:843-338-1186
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207197261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center