Provider Demographics
NPI:1437473543
Name:WEIGHT SHOP
Entity Type:Organization
Organization Name:WEIGHT SHOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:YVONNE
Authorized Official - Last Name:GRIMMETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-267-1202
Mailing Address - Street 1:953 DOUGHERTY RD
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-6508
Mailing Address - Country:US
Mailing Address - Phone:803-644-1970
Mailing Address - Fax:
Practice Address - Street 1:953 DOUGHERTY RD
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803-6508
Practice Address - Country:US
Practice Address - Phone:803-644-1970
Practice Address - Fax:803-644-1790
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRANDON L DANIELS M.D.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-18
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL30852207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC308526Medicaid
AA54290281Medicare PIN