Provider Demographics
NPI:1801407804
Name:FLORIDA WEIGHT LOSS LLC
Entity Type:Organization
Organization Name:FLORIDA WEIGHT LOSS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:FRESTA
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:941-705-2210
Mailing Address - Street 1:1590 79TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-4039
Mailing Address - Country:US
Mailing Address - Phone:941-705-2210
Mailing Address - Fax:
Practice Address - Street 1:1590 79TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-4039
Practice Address - Country:US
Practice Address - Phone:941-705-2210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1487264339Medicaid