Provider Demographics
NPI:1689116832
Name:MEDI WEIGHTLOSS
Entity Type:Organization
Organization Name:MEDI WEIGHTLOSS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:IVY
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-375-0537
Mailing Address - Street 1:4000 FIVE POINTS BLVD., SUITE 169
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76018
Mailing Address - Country:US
Mailing Address - Phone:817-375-0537
Mailing Address - Fax:
Practice Address - Street 1:4000 FIVE POINTS BLVD., SUITE 169
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76018
Practice Address - Country:US
Practice Address - Phone:817-375-0537
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP131658261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty