Healthcare Provider Details

I. General information

NPI: 1962717462
Provider Name (Legal Business Name): THE REFIT KOMPLEX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2010
Last Update Date: 08/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 9TH AVE
SEATTLE WA
98104
US

IV. Provider business mailing address

2414 1ST AVE SUITE 714
SEATTLE WA
98121-1345
US

V. Phone/Fax

Practice location:
  • Phone: 206-402-5040
  • Fax:
Mailing address:
  • Phone: 206-402-5040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name: MISS KAMINI R FONSECA
Title or Position: OWNER
Credential: LE, CPT, CGT,
Phone: 206-402-5040