Provider Demographics
NPI:1710342241
Name:SOUTHLAKE WEIGHT LOSS, LLC
Entity Type:Organization
Organization Name:SOUTHLAKE WEIGHT LOSS, LLC
Other - Org Name:MEDI-WEIGHTLOSS CLINICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:JOEL
Authorized Official - Last Name:OREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-271-4154
Mailing Address - Street 1:2050 SHADY OAKS DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-3510
Mailing Address - Country:US
Mailing Address - Phone:817-271-4154
Mailing Address - Fax:817-796-1595
Practice Address - Street 1:601 E SOUTHLAKE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6251
Practice Address - Country:US
Practice Address - Phone:817-488-1956
Practice Address - Fax:817-488-8675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE4781207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1043277221OtherNPI
TX1871868232OtherNPI
TX1558612325OtherNPI
TX1740308923OtherNPI
TX1376654988OtherNPI
TX1215094933OtherNPI