Provider Demographics
NPI:1912561861
Name:VAN DUSEN MEDICALLY SUPERVISED WEIGHT LOSS LLC
Entity Type:Organization
Organization Name:VAN DUSEN MEDICALLY SUPERVISED WEIGHT LOSS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN DUSEN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:207-975-1316
Mailing Address - Street 1:445 ASH POINT DR
Mailing Address - Street 2:
Mailing Address - City:OWLS HEAD
Mailing Address - State:ME
Mailing Address - Zip Code:04854-3601
Mailing Address - Country:US
Mailing Address - Phone:207-975-1316
Mailing Address - Fax:
Practice Address - Street 1:445 ASH POINT DR
Practice Address - Street 2:
Practice Address - City:OWLS HEAD
Practice Address - State:ME
Practice Address - Zip Code:04854-3601
Practice Address - Country:US
Practice Address - Phone:207-975-1316
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty