=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609121664
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOTAL FITNESS WELLNESS MS P
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2012
-----------------------------------------------------
Last Update Date | 07/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 HAMPTON DR
-----------------------------------------------------
City | SANDY SPRINGS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30350-3901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-572-1782
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 109 HAMPTON DR
-----------------------------------------------------
City | SANDY SPRINGS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30350-3901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-572-1782
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | WELLNESS AND FITNESS COACH
-----------------------------------------------------
Name | MISS PAULA F COPELAND
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-572-1782
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------