Provider Demographics
NPI:1316795214
Name:WESTERN RACQUET & FITNESS CLUB INC
Entity type:Organization
Organization Name:WESTERN RACQUET & FITNESS CLUB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN, DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TAD
Authorized Official - Middle Name:J
Authorized Official - Last Name:TAGGART
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, CD
Authorized Official - Phone:920-246-4886
Mailing Address - Street 1:2500 S ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5252
Mailing Address - Country:US
Mailing Address - Phone:920-497-1611
Mailing Address - Fax:
Practice Address - Street 1:2500 S ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5252
Practice Address - Country:US
Practice Address - Phone:920-497-1611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-07
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty