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General NPI Number Information
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NPI Number | 1508140500
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Entity Type | Organization
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Legal Business Name | INTERSPORT FITNESS CENTER
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Dates
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Enumeration Date | 10/10/2011
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Last Update Date | 10/13/2011
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Provider Practice Location Address
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Address Line | 4847 STRATOS WAY
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City | MODESTO
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State | CA
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Zip | 95356-9544
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Country | US
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Telephone | 209-522-9309
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Fax |
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Provider Business Mailing Address
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Address Line | 4847 STRATOS WAY
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City | MODESTO
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State | CA
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Zip | 95356-9544
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Country | US
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Telephone | 209-522-9309
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Fax | 209-522-9365
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Authorized Official
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Title or Position | OWNER
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Name | MRS. LORETTA GARCIA LAUGHLIN
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Credential | CPT
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Telephone | 209-480-9309
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174H00000X
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Taxonomy Name | Health Educator
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License Number | 164631
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License Number State | CA
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