Provider Demographics
NPI:1609061852
Name:THE INSTITUTE OF LIFESTYLE AND WEIGHT MANAGEMENT
Entity Type:Organization
Organization Name:THE INSTITUTE OF LIFESTYLE AND WEIGHT MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:EZRA
Authorized Official - Middle Name:BROOKS
Authorized Official - Last Name:WILKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-791-1112
Mailing Address - Street 1:3100 DURALEIGH RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-8106
Mailing Address - Country:US
Mailing Address - Phone:919-791-1112
Mailing Address - Fax:
Practice Address - Street 1:3100 DURALEIGH RD
Practice Address - Street 2:SUITE 200
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-8106
Practice Address - Country:US
Practice Address - Phone:919-791-1112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00987496261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center