Healthcare Provider Details

I. General information

NPI: 1275832149
Provider Name (Legal Business Name): TOP DOG NUTRITION & FITNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2011
Last Update Date: 03/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4708 GIBSON RD #105
OCEAN SPRINGS MS
39564-6042
US

IV. Provider business mailing address

4708 GIBSON RD #105
OCEAN SPRINGS MS
39564-6042
US

V. Phone/Fax

Practice location:
  • Phone: 228-872-1749
  • Fax: 228-872-1749
Mailing address:
  • Phone: 228-872-1749
  • Fax: 228-872-1749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number241367
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number234140
License Number StateFL

VIII. Authorized Official

Name: MISS SHEENA JOY MYLES
Title or Position: OPERATIONS MANAGER/CO-OWNER
Credential:
Phone: 228-872-1749