Healthcare Provider Details

I. General information

NPI: 1629822614
Provider Name (Legal Business Name): MAHOGANY 360 FITNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2024
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17325 EUCLID AVE STE 1094
CLEVELAND OH
44112-1247
US

IV. Provider business mailing address

PO BOX 43371
RICHMOND HEIGHTS OH
44143-0371
US

V. Phone/Fax

Practice location:
  • Phone: 216-282-7696
  • Fax:
Mailing address:
  • Phone: 216-282-7696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TE1100X
TaxonomyExercise & Sports Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MS. ANGELA BROWN
Title or Position: MANAGER
Credential:
Phone: 216-282-7696