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General NPI Number Information
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NPI Number | 1629417357
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Entity Type | Organization
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Legal Business Name | EXERCISING NUTRITIONALLY, LLC
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Dates
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Enumeration Date | 06/15/2013
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Last Update Date | 06/15/2013
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Provider Practice Location Address
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Address Line | 4225 NAPERVILLE RD ENLLC LOCATED WITHIN LIFESTART FITNESS CENTER
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City | LISLE
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State | IL
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Zip | 60532-3656
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Country | US
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Telephone | 630-303-3686
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Fax |
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Provider Business Mailing Address
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Address Line | 1943 PHAETON CT
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City | NAPERVILLE
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State | IL
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Zip | 60565-2410
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Country | US
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Telephone | 630-303-3686
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Fax |
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Authorized Official
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Title or Position | CEO/FOUNDER
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Name | DR. CRAIG E BROEDER
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Credential | PH.D. FACSM, FNAASO
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Telephone | 630-303-3686
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1100X
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Taxonomy Name | Research Clinic/Center
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License Number |
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License Number State |
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