Healthcare Provider Details

I. General information

NPI: 1265976963
Provider Name (Legal Business Name): 1ST STEP FITNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2016
Last Update Date: 12/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 RIVERPORT DR
JACKSON TN
38301-5748
US

IV. Provider business mailing address

95 RIVERPORT DR
JACKSON TN
38301-5748
US

V. Phone/Fax

Practice location:
  • Phone: 731-298-4506
  • Fax:
Mailing address:
  • Phone: 731-298-4506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateTN

VIII. Authorized Official

Name: JONATHAN LEE PARKER
Title or Position: OWNER
Credential:
Phone: 731-298-4506