Healthcare Provider Details

I. General information

NPI: 1780968263
Provider Name (Legal Business Name): REAL LIFE FITNESS SOLUTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2011
Last Update Date: 10/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1871 W CANYON VIEW DR
ST GEORGE UT
84770-5813
US

IV. Provider business mailing address

1871 W CANYON VIEW DR
ST GEORGE UT
84770-5813
US

V. Phone/Fax

Practice location:
  • Phone: 435-703-8090
  • Fax:
Mailing address:
  • Phone: 435-703-8090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name: ADAM FUNKE
Title or Position: DIRECTOR
Credential:
Phone: 435-703-8090