Healthcare Provider Details

I. General information

NPI: 1649549122
Provider Name (Legal Business Name): FUELING FITNESS PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2011
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 LAKESIDE AVE
BURLINGTON VT
05401-4939
US

IV. Provider business mailing address

3528 HARBOR RD
SHELBURNE VT
05482-7795
US

V. Phone/Fax

Practice location:
  • Phone: 802-777-9691
  • Fax: 216-357-5032
Mailing address:
  • Phone: 802-777-9691
  • Fax: 216-357-5032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number0740076077
License Number StateVT

VIII. Authorized Official

Name: MRS. MARCIA M BRISTOW
Title or Position: REGISTERED DITITIAN
Credential: MS RD CD
Phone: 802-777-9691