Healthcare Provider Details

I. General information

NPI: 1972677326
Provider Name (Legal Business Name): NATICK SPORTS AND RACQUET CLUB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 OAK ST LONGFELLOW SPORTS CLUB
NATICK MA
01760-1306
US

IV. Provider business mailing address

203 OAK ST LONGFELLOW SPORTS CLUB
NATICK MA
01760-1306
US

V. Phone/Fax

Practice location:
  • Phone: 508-653-4633
  • Fax: 508-650-4986
Mailing address:
  • Phone: 508-653-4633
  • Fax: 508-650-4986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLDN1011
License Number StateMA

VIII. Authorized Official

Name: MISS JANE POLLEY
Title or Position: DIETITIAN
Credential: M.S., R.D., LDN
Phone: 508-653-4633