Provider Demographics
NPI:1740748870
Name:SOUTHERN WEIGHT LOSS CLINIC, LLC
Entity Type:Organization
Organization Name:SOUTHERN WEIGHT LOSS CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BETSY
Authorized Official - Middle Name:
Authorized Official - Last Name:STANRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-628-5633
Mailing Address - Street 1:3600 DALLAS HWY SW STE 210
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-1687
Mailing Address - Country:US
Mailing Address - Phone:770-628-5633
Mailing Address - Fax:
Practice Address - Street 1:3600 DALLAS HWY SW STE 210
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-1687
Practice Address - Country:US
Practice Address - Phone:770-628-5633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-07
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty