Healthcare Provider Details

I. General information

NPI: 1053641555
Provider Name (Legal Business Name): 6WEEKWORKOUT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2010
Last Update Date: 01/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3691 S CARSON ST
CARSON CITY NV
89701-5567
US

IV. Provider business mailing address

3691 S CARSON ST
CARSON CITY NV
89701-5567
US

V. Phone/Fax

Practice location:
  • Phone: 775-790-9679
  • Fax: 775-883-6840
Mailing address:
  • Phone: 775-790-9679
  • Fax: 775-883-6840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number0900026381
License Number StateNV

VIII. Authorized Official

Name: MR. ARIK JEFFERY BANNISTER
Title or Position: MANAGER
Credential:
Phone: 775-790-9481