Basic Information
| Provider Information | |||||||||
| NPI: | 1184174914 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MADISON HEALTHPLEX AND SPORTS PERFORMANCE CENTER LLC | ||||||||
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| OtherOrganizationName: | MADISON HEALTHPLEX PERFORMANCE TRAINING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 BAPTIST DR | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391102030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018567757 | ||||||||
| FaxNumber: | 6019449780 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 BAPTIST DR | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391102030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018567757 | ||||||||
| FaxNumber: | 6019449780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2016 | ||||||||
| LastUpdateDate: | 10/05/2016 | ||||||||
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| AuthorizedOfficialLastName: | CENTILLI | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6018567757 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.