MEDICARE: ERICH FORTENBERRY CERT FITNESS TRAINER

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	174H00000X	Health Educator

General Provider Information

NPI Number	:	1326414764
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERICH FORTENBERRY CERT FITNESS TRAINER

Provider Business Mailing Address
First Line	:	5100 KANSAS AVE NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20011-3215
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5100 KANSAS AVE NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20011-3215
Country	:	US
Telephone Number	:	202-360-0185
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2015
Last Update Date	:	08/20/2015

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