Provider Demographics
NPI:1518401181
Name:THE WEIGHT LOSS & DIABETES CENTER, LLC
Entity Type:Organization
Organization Name:THE WEIGHT LOSS & DIABETES CENTER, LLC
Other - Org Name:THE WEIGHT LOSS & DIABETES CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MOSUNIC
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:207-699-4225
Mailing Address - Street 1:1600 CONGRESS ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2143
Mailing Address - Country:US
Mailing Address - Phone:207-699-4225
Mailing Address - Fax:
Practice Address - Street 1:1600 CONGRESS ST
Practice Address - Street 2:SUITE C
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2143
Practice Address - Country:US
Practice Address - Phone:207-699-4225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-15
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1438103TC0700X
MECNP141070363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty