Provider Demographics
NPI:1063852069
Name:DOCTORS WEIGHT LOSS CENTER & WELLNESS
Entity Type:Organization
Organization Name:DOCTORS WEIGHT LOSS CENTER & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ADYS
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRABAL
Authorized Official - Suffix:
Authorized Official - Credentials:VICE PRESIDENT
Authorized Official - Phone:512-782-2084
Mailing Address - Street 1:11215 S INTERSTATE 35
Mailing Address - Street 2:SUITE 114
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78747-1863
Mailing Address - Country:US
Mailing Address - Phone:512-782-2084
Mailing Address - Fax:512-782-2088
Practice Address - Street 1:11215 S INTERSTATE 35
Practice Address - Street 2:SUITE 114
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78747-1863
Practice Address - Country:US
Practice Address - Phone:512-782-2084
Practice Address - Fax:512-782-2088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-05
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX736533364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult HealthGroup - Single Specialty