=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427766153
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JM FITNESS AND WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2022
-----------------------------------------------------
Last Update Date | 11/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 RADCLIFF DR
-----------------------------------------------------
City | NYACK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10960-1012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-887-2082
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 210 RADCLIFF DR
-----------------------------------------------------
City | NYACK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10960-1012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JASON MACHOWSKY
-----------------------------------------------------
Credential | RDN, CSSD, CEP
-----------------------------------------------------
Telephone | 732-887-2082
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------