Healthcare Provider Details

I. General information

NPI: 1801227723
Provider Name (Legal Business Name): KIDZ FITNESS STATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2013
Last Update Date: 03/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 TERRY RD
JACKSON MS
39204-5767
US

IV. Provider business mailing address

1389 MUNDYS MILL RD
JONESBORO GA
30238-6082
US

V. Phone/Fax

Practice location:
  • Phone: 404-279-0598
  • 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 TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: ASYA JOY SMITH
Title or Position: OWNER
Credential:
Phone: 404-279-0598