Healthcare Provider Details

I. General information

NPI: 1205630852
Provider Name (Legal Business Name): FITNESS360
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2025
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 DEL NORTE RD STE 220A
CAMARILLO CA
93010-8621
US

IV. Provider business mailing address

1574 TAMARIX ST
CAMARILLO CA
93010-1945
US

V. Phone/Fax

Practice location:
  • Phone: 805-607-9515
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: NICOLE BURBOA
Title or Position: CEO
Credential:
Phone: 805-607-9515