Provider Demographics
NPI:1427418490
Name:INNOVATIVE WEIGHT LOSS SOLUTIONS, LLC
Entity Type:Organization
Organization Name:INNOVATIVE WEIGHT LOSS SOLUTIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:FEDERICO
Authorized Official - Middle Name:
Authorized Official - Last Name:GREGORY-GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-946-5220
Mailing Address - Street 1:1353 AVE. LUIS VIGOREAUX
Mailing Address - Street 2:PMB 466
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00966
Mailing Address - Country:US
Mailing Address - Phone:787-946-5220
Mailing Address - Fax:787-946-5220
Practice Address - Street 1:101 AVE SAN PATRICIO STE 1050
Practice Address - Street 2:
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00968-3049
Practice Address - Country:US
Practice Address - Phone:787-946-5220
Practice Address - Fax:787-946-5220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14704207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR14704OtherMD