Provider Demographics
NPI:1952031338
Name:THE WEIGHT LOSS AND PAIN CLINIC LLC
Entity Type:Organization
Organization Name:THE WEIGHT LOSS AND PAIN CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED NUTRITIONIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUNNICUTT
Authorized Official - Suffix:
Authorized Official - Credentials:BCHHP
Authorized Official - Phone:580-309-2828
Mailing Address - Street 1:1315 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:OK
Mailing Address - Zip Code:73096-2443
Mailing Address - Country:US
Mailing Address - Phone:580-309-2828
Mailing Address - Fax:
Practice Address - Street 1:1315 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:OK
Practice Address - Zip Code:73096-2443
Practice Address - Country:US
Practice Address - Phone:508-309-2828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, PediatricGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1111Medicaid