Provider Demographics
NPI:1639312960
Name:BODY WISE WEIGHT LOSS & AESTHETICS CENTER INC
Entity Type:Organization
Organization Name:BODY WISE WEIGHT LOSS & AESTHETICS CENTER INC
Other - Org Name:BODY WISE MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MIKEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-289-5252
Mailing Address - Street 1:3921 E BASELINE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2727
Mailing Address - Country:US
Mailing Address - Phone:480-289-5252
Mailing Address - Fax:480-776-5169
Practice Address - Street 1:3921 E BASELINE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2727
Practice Address - Country:US
Practice Address - Phone:480-289-5252
Practice Address - Fax:480-776-5169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-16
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ212292083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Single Specialty