Provider Demographics
NPI:1972677326
Name:NATICK SPORTS AND RACQUET CLUB
Entity Type:Organization
Organization Name:NATICK SPORTS AND RACQUET CLUB
Other - Org Name:LONGFELLOW SPORTS CLUB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIETITIAN
Authorized Official - Prefix:MISS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:POLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, LDN
Authorized Official - Phone:508-653-4633
Mailing Address - Street 1:203 OAK ST
Mailing Address - Street 2:LONGFELLOW SPORTS CLUB
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760-1306
Mailing Address - Country:US
Mailing Address - Phone:508-653-4633
Mailing Address - Fax:508-650-4986
Practice Address - Street 1:203 OAK ST
Practice Address - Street 2:LONGFELLOW SPORTS CLUB
Practice Address - City:NATICK
Practice Address - State:MA
Practice Address - Zip Code:01760-1306
Practice Address - Country:US
Practice Address - Phone:508-653-4633
Practice Address - Fax:508-650-4986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALDN1011133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6300209OtherUNITED HEALTH CARE
MA5582051OtherAETNA
MA39410OtherHARVARD PILGRIM HEALTH
MA763282OtherTUFTS
MALD0022OtherBLUE CROSS BLUE SHIELD
MT0238Medicare ID - Type Unspecified