MEDICARE: ULTIMATE RESULTS AT SOUTH RIDING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174H00000X	Health Educator

General Provider Information

NPI Number	:	1114275237
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ULTIMATE RESULTS AT SOUTH RIDING

Provider Business Mailing Address
First Line	:	25055 RIDING PLZ
Second Line	:	SUITE 130
City	:	CHANTILLY
State	:	VA
Zip	:	20152-5917
Country	:	US
Telephone Number	:	703-220-6917
Fax Number	:

Provider Business Practice Location Address
First Line	:	25055 RIDING PLZ
Second Line	:	SUITE 130
City	:	CHANTILLY
State	:	VA
Zip	:	20152-5917
Country	:	US
Telephone Number	:	703-220-6917
Fax Number	:

Authorized Official
Title or Position	:	OWNER, HEAD TRAINER
Name	:	MR. NICHOLAS ALEXANDER FURST
Credential	:	CPT
Telephone Number	:	703-220-6917

Provider Enumeration Date	:	08/21/2012
Last Update Date	:	08/21/2012

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