Provider Demographics
NPI:1518205947
Name:ADVANCED WEIGHT LOSS CLINIC, L.L.C.
Entity Type:Organization
Organization Name:ADVANCED WEIGHT LOSS CLINIC, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROFFESSIONAL
Authorized Official - Prefix:
Authorized Official - First Name:BRITTANY
Authorized Official - Middle Name:
Authorized Official - Last Name:HALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-743-5113
Mailing Address - Street 1:6809 SOUTH STATE HWY 14
Mailing Address - Street 2:
Mailing Address - City:CLEVER
Mailing Address - State:MO
Mailing Address - Zip Code:65631
Mailing Address - Country:US
Mailing Address - Phone:417-743-5113
Mailing Address - Fax:417-743-5113
Practice Address - Street 1:6809 STATE HIGHWAY 14 W
Practice Address - Street 2:
Practice Address - City:CLEVER
Practice Address - State:MO
Practice Address - Zip Code:65631-6799
Practice Address - Country:US
Practice Address - Phone:417-743-5113
Practice Address - Fax:417-743-5113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-18
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization