Provider Demographics
NPI:1275801508
Name:NEW DIRECTIONS PHYSICIAN WEIGHT LOSS
Entity Type:Organization
Organization Name:NEW DIRECTIONS PHYSICIAN WEIGHT LOSS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SAMS
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:479-268-6404
Mailing Address - Street 1:5501 PINNACLE PT DR
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8131
Mailing Address - Country:US
Mailing Address - Phone:479-268-6404
Mailing Address - Fax:479-657-6315
Practice Address - Street 1:5501 PINNACLE PT DR
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8131
Practice Address - Country:US
Practice Address - Phone:479-268-6404
Practice Address - Fax:479-657-6315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-01
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR0543133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty