Provider Demographics
NPI:1598425761
Name:GYMBOOM LLC
Entity Type:Organization
Organization Name:GYMBOOM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:EMMA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BACKES
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:320-309-8913
Mailing Address - Street 1:3250 W 66TH ST APT 548
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5514
Mailing Address - Country:US
Mailing Address - Phone:320-309-8913
Mailing Address - Fax:
Practice Address - Street 1:3250 W 66TH ST APT 548
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5514
Practice Address - Country:US
Practice Address - Phone:320-309-8913
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty