Provider Demographics
NPI:1417632175
Name:PREMIER WEIGHT LOSS MANAGEMENT
Entity Type:Organization
Organization Name:PREMIER WEIGHT LOSS MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUDELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-344-8038
Mailing Address - Street 1:122 CANAL ST STE 102
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-4408
Mailing Address - Country:US
Mailing Address - Phone:912-450-0999
Mailing Address - Fax:912-450-0998
Practice Address - Street 1:122 CANAL ST STE 102
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4408
Practice Address - Country:US
Practice Address - Phone:912-450-0999
Practice Address - Fax:912-450-0998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083B0002XAllopathic & Osteopathic PhysiciansPreventive MedicineObesity MedicineGroup - Multi-Specialty