Provider Demographics
NPI:1326474271
Name:HORMONE HEALTH AND WEIGHT LOSS
Entity Type:Organization
Organization Name:HORMONE HEALTH AND WEIGHT LOSS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:CHASTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-527-2000
Mailing Address - Street 1:11363 SAN JOSE BLVD
Mailing Address - Street 2:ST. 102
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-7957
Mailing Address - Country:US
Mailing Address - Phone:904-527-2000
Mailing Address - Fax:904-527-2001
Practice Address - Street 1:11363 SAN JOSE BLVD
Practice Address - Street 2:ST. 102
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-7957
Practice Address - Country:US
Practice Address - Phone:904-527-2000
Practice Address - Fax:904-527-2001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-24
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL604198261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service