MEDICARE: KNOCKOUTBODYFITTNESS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1285097733
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KNOCKOUTBODYFITTNESS

Provider Business Mailing Address
First Line	:	791 MARION AVE SE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30312-3615
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	791 MARION AVE SE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30312-3615
Country	:	US
Telephone Number	:	678-637-8318
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	KEISHA OLIVER
Credential	:
Telephone Number	:	678-637-8318

Provider Enumeration Date	:	04/01/2016
Last Update Date	:	04/01/2016

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Directions to “KNOCKOUTBODYFITTNESS ” Practice Location

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