Provider Demographics
NPI:1023462645
Name:UNIVERSAL ATHLETIC CLUB
Entity type:Organization
Organization Name:UNIVERSAL ATHLETIC CLUB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:CASSELBURY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-569-5396
Mailing Address - Street 1:2323 OREGON PIKE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-4608
Mailing Address - Country:US
Mailing Address - Phone:717-569-5396
Mailing Address - Fax:717-569-4989
Practice Address - Street 1:2323 OREGON PIKE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-4608
Practice Address - Country:US
Practice Address - Phone:717-569-5396
Practice Address - Fax:717-569-4989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN003167133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty