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General NPI Number Information
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NPI Number | 1699487025
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Entity Type | Organization
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Legal Business Name | FITNESS RELATED ACTIVITIES AND MARTIAL ARTS
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Dates
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Enumeration Date | 12/16/2022
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Last Update Date | 12/16/2022
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Provider Practice Location Address
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Address Line | 953 E SAHARA AVE STE A33
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City | LAS VEGAS
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State | NV
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Zip | 89104-3031
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Country | US
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Telephone | 702-327-1828
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 60172
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City | LAS VEGAS
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State | NV
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Zip | 89160-0172
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Country | US
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Telephone | 702-327-1828
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Fax |
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Authorized Official
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Title or Position | GENERAL MANAGER
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Name | ANGEL MONTES DE OCA
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Credential |
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Telephone | 702-327-1828
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number |
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License Number State |
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