Provider Demographics
NPI:1720368905
Name:GULFPORT MEDICAL WEIGHT LOSS
Entity Type:Organization
Organization Name:GULFPORT MEDICAL WEIGHT LOSS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EVA
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-330-8220
Mailing Address - Street 1:12337 ASHLEY DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-2753
Mailing Address - Country:US
Mailing Address - Phone:251-330-8220
Mailing Address - Fax:
Practice Address - Street 1:12337 ASHLEY DR
Practice Address - Street 2:SUITE F
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2753
Practice Address - Country:US
Practice Address - Phone:251-330-8220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty