Provider Demographics
NPI:1013117241
Name:LIFEBRIDGE HEALTH AND FITNESS LLC
Entity Type:Organization
Organization Name:LIFEBRIDGE HEALTH AND FITNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:FAJERSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-318-6816
Mailing Address - Street 1:1836 GREENE TREE RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-1381
Mailing Address - Country:US
Mailing Address - Phone:410-484-6800
Mailing Address - Fax:410-484-6804
Practice Address - Street 1:1836 GREENE TREE RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21208-1381
Practice Address - Country:US
Practice Address - Phone:410-484-6800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFEBRIDGE HEALTH & FITNESS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-25
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No261QR0404XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Cardiac FacilitiesGroup - Multi-Specialty