MEDICARE: INDEPENDENT PERSONAL TRAINING STUDIOS

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	251K00000X	Public Health or Welfare Agency

General Provider Information

NPI Number	:	1831636893
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENT PERSONAL TRAINING STUDIOS

Provider Business Mailing Address
First Line	:	13214 ASHFORD PARK DR
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27613-4143
Country	:	US
Telephone Number	:	919-280-8593
Fax Number	:

Provider Business Practice Location Address
First Line	:	6503 HILBURN DR
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27613-1908
Country	:	US
Telephone Number	:	919-280-8593
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	MR. DARVIS SIMMS
Credential	:
Telephone Number	:	919-280-8593

Provider Enumeration Date	:	01/27/2017
Last Update Date	:	01/27/2017

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