Healthcare Provider Details

I. General information

NPI: 1225648397
Provider Name (Legal Business Name): C.L.U.B BLESSED WEIGHT MANAGEMENT INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2020
Last Update Date: 08/04/2020
Certification Date: 08/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 MAIN ST
PAWTUCKET RI
02860-4016
US

IV. Provider business mailing address

102 MOORE ST
PROVIDENCE RI
02907-1505
US

V. Phone/Fax

Practice location:
  • Phone: 774-379-9761
  • Fax:
Mailing address:
  • Phone: 774-379-9761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE JEAN BARBOZA
Title or Position: FITNESS & NUTRITION SPECIALIST
Credential: CERTIFIED
Phone: 774-379-9761