Healthcare Provider Details

I. General information

NPI: 1952875049
Provider Name (Legal Business Name): VEGAFIT ELITE FITNESS AND TRAINING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2019
Last Update Date: 01/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91-2131 KAIOLI ST #3403
EWA BEACH HI
96706
US

IV. Provider business mailing address

91-2131 KAIOLI ST #3403
EWA BEACH HI
96706
US

V. Phone/Fax

Practice location:
  • Phone: 808-260-0210
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: SHANE VEGA
Title or Position: OWNER/FOUNDER
Credential:
Phone: 808-260-0210