Provider Demographics
NPI:1518736149
Name:TOTAL BODY RENEWAL MEDICAL WEIGHT MANAGEMENT AND LASER TREATMENT CENTE
Entity Type:Organization
Organization Name:TOTAL BODY RENEWAL MEDICAL WEIGHT MANAGEMENT AND LASER TREATMENT CENTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-967-9859
Mailing Address - Street 1:10400 ADRIAN RD
Mailing Address - Street 2:
Mailing Address - City:MASCOUTAH
Mailing Address - State:IL
Mailing Address - Zip Code:62258-4344
Mailing Address - Country:US
Mailing Address - Phone:618-967-9859
Mailing Address - Fax:
Practice Address - Street 1:420 COLUMBIA CTR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-2540
Practice Address - Country:US
Practice Address - Phone:618-719-2011
Practice Address - Fax:618-417-6046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-22
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty