Healthcare Provider Details

I. General information

NPI: 1932733144
Provider Name (Legal Business Name): MGFITLIFE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2020
Last Update Date: 08/11/2020
Certification Date: 08/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 GATSBY GLEN DR
VERONA WI
53593-2255
US

IV. Provider business mailing address

701 GATSBY GLEN DR
VERONA WI
53593-2255
US

V. Phone/Fax

Practice location:
  • Phone: 651-336-8962
  • Fax:
Mailing address:
  • Phone: 651-336-8962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL R GORSKI
Title or Position: OWNER
Credential: RD, CD
Phone: 651-336-8962