Provider Demographics
NPI:1376925602
Name:GLENDALE WEIGHTLOSS LLC
Entity Type:Organization
Organization Name:GLENDALE WEIGHTLOSS LLC
Other - Org Name:MEDI-WEIGHTLOSS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:KALOUST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-228-6334
Mailing Address - Street 1:509 S HYDE PARK AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-2266
Mailing Address - Country:US
Mailing Address - Phone:813-228-6334
Mailing Address - Fax:813-228-6763
Practice Address - Street 1:5310 W THUNDERBIRD RD
Practice Address - Street 2:STE 308
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4706
Practice Address - Country:US
Practice Address - Phone:623-825-7931
Practice Address - Fax:623-240-2673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ500010862207QB0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity MedicineGroup - Single Specialty