Healthcare Provider Details

I. General information

NPI: 1265885529
Provider Name (Legal Business Name): THE FEARLESS FORK, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2016
Last Update Date: 11/28/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 SCHOOL HOUSE RD STE 14
ORLAND ME
04472-3966
US

IV. Provider business mailing address

21 SCHOOL HOUSE RD STE 14
ORLAND ME
04472-3966
US

V. Phone/Fax

Practice location:
  • Phone: 207-752-2341
  • Fax: 207-702-9224
Mailing address:
  • Phone: 297-752-2341
  • Fax: 855-752-0261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: MARYBETH JUDY
Title or Position: PRESIDENT
Credential: MS. RDN, CSR, LD
Phone: 207-752-2341