Provider Demographics
NPI:1194948034
Name:JUMPSTART FITNESS INC
Entity type:Organization
Organization Name:JUMPSTART FITNESS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MELONIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:706-276-2000
Mailing Address - Street 1:PO BOX 146
Mailing Address - Street 2:
Mailing Address - City:EAST ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30539-0003
Mailing Address - Country:US
Mailing Address - Phone:706-276-2000
Mailing Address - Fax:706-276-2080
Practice Address - Street 1:60 OLD HIGHWAY 5 S
Practice Address - Street 2:
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-5436
Practice Address - Country:US
Practice Address - Phone:170-627-6200
Practice Address - Fax:706-276-2080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001550152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA910061011AMedicaid
GA=========OtherTIN
GA910061011AMedicaid
GA41ZCFPKMedicare Oscar/Certification
GA41ZCFPKMedicare PIN