=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871862755
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAMPSHIRE HILLS SPORT & FITNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2011
-----------------------------------------------------
Last Update Date | 12/21/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 EMERSON RD
-----------------------------------------------------
City | MILFORD
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03055-3516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-673-7123
-----------------------------------------------------
Fax | 603-673-0797
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 EMERSON ROAD P.O. BOX 404
-----------------------------------------------------
City | MILFORD
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-673-7123
-----------------------------------------------------
Fax | 603-673-0797
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ GENERAL MANAGER
-----------------------------------------------------
Name | MR. RICK HOLDER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 603-673-7123
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 133NN1002X
-----------------------------------------------------
Taxonomy Name | Nutrition Education Nutritionist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------