Provider Demographics
NPI:1891090858
Name:WEIGHT LOSS INSTITUTE INC
Entity Type:Organization
Organization Name:WEIGHT LOSS INSTITUTE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:DACOSTA
Authorized Official - Last Name:A
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-674-8866
Mailing Address - Street 1:22 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-5502
Mailing Address - Country:US
Mailing Address - Phone:973-674-8866
Mailing Address - Fax:973-672-9299
Practice Address - Street 1:268 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-2011
Practice Address - Country:US
Practice Address - Phone:973-674-8866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05600200174400000X
NJ25MA07916100174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty