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NPI Code Detail

MEDICARE: EXECUTIVE FITNESS INC

MEDICARE: EXECUTIVE FITNESS INC
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
1174400000XSpecialist2408NV

General Provider Information

NPI Number : 1144552316
Entity Type Code : Organization
Provider Name (Legal Business Name) : EXECUTIVE FITNESS INC
Provider Business Mailing Address
First Line : 6440 MEDICAL CENTER ST STE 100
Second Line :
City : LAS VEGAS
State : NV
Zip : 89148-2404
Country : US
Telephone Number : 702-222-1000
Fax Number : 702-222-9448
Provider Business Practice Location Address
First Line : 6440 MEDICAL CENTER ST STE 100
Second Line :
City : LAS VEGAS
State : NV
Zip : 89148-2404
Country : US
Telephone Number : 702-222-1000
Fax Number : 702-222-9448
Authorized Official
Title or Position : OFFICE MANAGER
Name : JACKIE DICKINSON
Credential :
Telephone Number : 702-222-1000
Provider Enumeration Date : 02/12/2010
Last Update Date : 02/12/2010

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1538649025 — BRODERICK A BRASS DPT
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Directions to “EXECUTIVE FITNESS INC ” Practice Location

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