Provider Demographics
NPI:1063304558
Name:ORANGE SHOE PERSONAL FITNESS
Entity type:Organization
Organization Name:ORANGE SHOE PERSONAL FITNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN/CO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAYDEN
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:CLEMETSON
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, MS, CD, CLC
Authorized Official - Phone:262-347-1843
Mailing Address - Street 1:1450 CAPITOL DR UNIT C
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-2608
Mailing Address - Country:US
Mailing Address - Phone:262-347-1843
Mailing Address - Fax:
Practice Address - Street 1:14960 W GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-7005
Practice Address - Country:US
Practice Address - Phone:262-347-1843
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-17
Last Update Date:2025-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty