Provider Demographics
NPI:1245394394
Name:WEIGHT LOSS SURGERY CENTER
Entity Type:Organization
Organization Name:WEIGHT LOSS SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOYNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-591-9572
Mailing Address - Street 1:645 J CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1819
Mailing Address - Country:US
Mailing Address - Phone:757-591-9572
Mailing Address - Fax:757-591-9606
Practice Address - Street 1:645 J CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-1819
Practice Address - Country:US
Practice Address - Phone:757-591-9572
Practice Address - Fax:757-591-9606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101050712174400000X
VA0101236493174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA138438OtherANTHEM DR. TERRACINA
VA453810OtherANTHEM DR. THOMAS CLARK
VA7312059Medicaid
VA7312059Medicaid
VAF57869Medicare UPIN
VA453810OtherANTHEM DR. THOMAS CLARK