Provider Demographics
NPI:1225103369
Name:HEALTHY STEPS WEIGHT LOSS CENTER MEDICAL CORPORATION
Entity Type:Organization
Organization Name:HEALTHY STEPS WEIGHT LOSS CENTER MEDICAL CORPORATION
Other - Org Name:HEALTHY STEPS WEIGHT LOSS CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:O
Authorized Official - Last Name:WOODBURY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-577-7800
Mailing Address - Street 1:4730 HOEN AVENUE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405
Mailing Address - Country:US
Mailing Address - Phone:707-577-7800
Mailing Address - Fax:707-525-0538
Practice Address - Street 1:4730 HOEN AVENUE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405
Practice Address - Country:US
Practice Address - Phone:707-577-7800
Practice Address - Fax:707-525-0538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0102070Medicaid
ZZZ03645ZMedicare PIN
222036452Medicare PIN