Provider Demographics
NPI:1295092229
Name:SHANE FIT
Entity type:Organization
Organization Name:SHANE FIT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAIDENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-797-9977
Mailing Address - Street 1:134 TEATOWN RD
Mailing Address - Street 2:
Mailing Address - City:CROTON ON HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:10520-3524
Mailing Address - Country:US
Mailing Address - Phone:626-797-9977
Mailing Address - Fax:
Practice Address - Street 1:134 TEATOWN ROAD
Practice Address - Street 2:
Practice Address - City:CROTON ON HUDSON
Practice Address - State:CA
Practice Address - Zip Code:90265
Practice Address - Country:US
Practice Address - Phone:626-797-9977
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR049213-1132700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes132700000XDietary & Nutritional Service ProvidersDietary ManagerGroup - Single Specialty