Healthcare Provider Details

I. General information

NPI: 1548068703
Provider Name (Legal Business Name): KIDISTHENICS FITNESS COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2025
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15415 EASTVALE RD
POWAY CA
92064-2340
US

IV. Provider business mailing address

2907 SHELTER ISLAND DR STE 105
SAN DIEGO CA
92106-2797
US

V. Phone/Fax

Practice location:
  • Phone: 619-992-2753
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333300000X
TaxonomyEmergency Response System Companies
License Number
License Number State

VIII. Authorized Official

Name: RYAN BIGELOW
Title or Position: CHIEF OPERATIONS OFFICER
Credential:
Phone: 619-992-2753