Provider Demographics
NPI:1093943219
Name:MEDSHAPE WEIGHT LOSS CLINIC, LLC
Entity Type:Organization
Organization Name:MEDSHAPE WEIGHT LOSS CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-276-3742
Mailing Address - Street 1:7972 W THUNDERBIRD RD
Mailing Address - Street 2:106
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4903
Mailing Address - Country:US
Mailing Address - Phone:623-412-2700
Mailing Address - Fax:623-776-3065
Practice Address - Street 1:7972 W THUNDERBIRD RD
Practice Address - Street 2:106
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4903
Practice Address - Country:US
Practice Address - Phone:623-412-2700
Practice Address - Fax:623-776-3065
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDSHAPE WEIGHT LOSS CLINIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-25
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty