Provider Demographics
NPI:1023581576
Name:ISLAND WEIGHT LOSS
Entity type:Organization
Organization Name:ISLAND WEIGHT LOSS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:LAURIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-453-2410
Mailing Address - Street 1:1365 N COURTENAY PKWY
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4405
Mailing Address - Country:US
Mailing Address - Phone:321-453-2410
Mailing Address - Fax:
Practice Address - Street 1:1365 N COURTENAY PKWY
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4405
Practice Address - Country:US
Practice Address - Phone:321-453-2410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ISLAND WEIGHT LOSS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity MedicineGroup - Single Specialty