Provider Demographics
NPI:1417230186
Name:DIVA WEIGHT LOSS LLC
Entity Type:Organization
Organization Name:DIVA WEIGHT LOSS LLC
Other - Org Name:B/BA PERFORMANCE WEIGHT LOSS AND MEDISPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARYN
Authorized Official - Middle Name:ALISON
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:601-624-5840
Mailing Address - Street 1:604 GOODRIDGE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-4402
Mailing Address - Country:US
Mailing Address - Phone:769-251-1040
Mailing Address - Fax:
Practice Address - Street 1:604 GOODRIDGE DR
Practice Address - Street 2:SUITE A
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4402
Practice Address - Country:US
Practice Address - Phone:769-251-1040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-20
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR869964261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service