Provider Demographics
NPI:1407115710
Name:PREMIER WEIGHT LOSS MEDICAL CLINIC
Entity Type:Organization
Organization Name:PREMIER WEIGHT LOSS MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:KUTSINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-832-9080
Mailing Address - Street 1:719 S AVERILL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3813
Mailing Address - Country:US
Mailing Address - Phone:310-832-9080
Mailing Address - Fax:310-832-9027
Practice Address - Street 1:719 S AVERILL AVE
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3813
Practice Address - Country:US
Practice Address - Phone:310-832-9080
Practice Address - Fax:310-832-9027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-07
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes132700000XDietary & Nutritional Service ProvidersDietary ManagerGroup - Single Specialty