Provider Demographics
NPI:1497127468
Name:WEIGHT LOSS CLINIC OF COLLEGE STATION, LLC
Entity Type:Organization
Organization Name:WEIGHT LOSS CLINIC OF COLLEGE STATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:JOEL
Authorized Official - Last Name:OREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-271-4154
Mailing Address - Street 1:2050 SHADY OAKS DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-3510
Mailing Address - Country:US
Mailing Address - Phone:817-271-4154
Mailing Address - Fax:817-796-1595
Practice Address - Street 1:1105 UNIVERSITY DR E
Practice Address - Street 2:SUITE 100
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77840-2183
Practice Address - Country:US
Practice Address - Phone:979-393-0369
Practice Address - Fax:979-446-0755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-29
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6399207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1740380923OtherNPI
TX1790890259OtherNPI
TX1669792321OtherNPI
TX1851710347OtherNPI