Provider Demographics
NPI:1922412683
Name:ADVANCED MEDICAL WEIGHT LOSS CENTER
Entity Type:Organization
Organization Name:ADVANCED MEDICAL WEIGHT LOSS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-294-0444
Mailing Address - Street 1:1490 LANE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:BOGART
Mailing Address - State:GA
Mailing Address - Zip Code:30622-2627
Mailing Address - Country:US
Mailing Address - Phone:678-294-0444
Mailing Address - Fax:
Practice Address - Street 1:1100 SPRING ST NW
Practice Address - Street 2:SUITE 150
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-2846
Practice Address - Country:US
Practice Address - Phone:678-294-0444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty