Healthcare Provider Details

I. General information

NPI: 1366803561
Provider Name (Legal Business Name): DEFINED FITNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2016
Last Update Date: 03/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4930 MCLEOD RD NE
ALBUQUERQUE NM
87109-2118
US

IV. Provider business mailing address

4930 MCLEOD RD NE
ALBUQUERQUE NM
87109-2118
US

V. Phone/Fax

Practice location:
  • Phone: 505-349-4444
  • Fax:
Mailing address:
  • Phone: 505-349-4444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number121001
License Number StateNM

VIII. Authorized Official

Name: LAURA GEORGE
Title or Position: CFO
Credential:
Phone: 505-349-4444