Healthcare Provider Details

I. General information

NPI: 1912352022
Provider Name (Legal Business Name): FITNESS CLINIC WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2016
Last Update Date: 02/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2219 GREENWAY DR
JACKSON MS
39204-3202
US

IV. Provider business mailing address

2219 GREENWAY DR
JACKSON MS
39204-3202
US

V. Phone/Fax

Practice location:
  • Phone: 601-983-7494
  • Fax:
Mailing address:
  • Phone: 601-983-7494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number871546
License Number StateMS

VIII. Authorized Official

Name: MS. BARBARA BROADWATER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 601-983-7494