Healthcare Provider Details

I. General information

NPI: 1558958009
Provider Name (Legal Business Name): GEORGETOWN FITNESS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2020
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5225 SHERIDAN DR
WILLIAMSVILLE NY
14221-3573
US

IV. Provider business mailing address

5225 SHERIDAN DR
WILLIAMSVILLE NY
14221-3573
US

V. Phone/Fax

Practice location:
  • Phone: 716-580-3362
  • Fax:
Mailing address:
  • Phone: 607-280-3441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133VN1301X
TaxonomyOncology Nutrition Registered Dietitian
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID JACOBS JR.
Title or Position: OWNER
Credential:
Phone: 607-280-3441