Provider Demographics
NPI:1629417357
Name:EXERCISING NUTRITIONALLY, LLC
Entity Type:Organization
Organization Name:EXERCISING NUTRITIONALLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:E
Authorized Official - Last Name:BROEDER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD FACSM, FNAASO
Authorized Official - Phone:630-303-3686
Mailing Address - Street 1:1943 PHAETON CT
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60565-2410
Mailing Address - Country:US
Mailing Address - Phone:630-303-3686
Mailing Address - Fax:
Practice Address - Street 1:4225 NAPERVILLE RD
Practice Address - Street 2:ENLLC LOCATED WITHIN LIFESTART FITNESS CENTER
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-3656
Practice Address - Country:US
Practice Address - Phone:630-303-3686
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-15
Last Update Date:2013-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1100XAmbulatory Health Care FacilitiesClinic/CenterResearch