Provider Demographics
NPI:1205616398
Name:COUNTRY CLUB MEDICAL WEIGHT LOSS & WELLNESS PLLC
Entity type:Organization
Organization Name:COUNTRY CLUB MEDICAL WEIGHT LOSS & WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FLORA
Authorized Official - Middle Name:
Authorized Official - Last Name:ISSANDA STOWATER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:480-840-4777
Mailing Address - Street 1:PO BOX 697
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-0697
Mailing Address - Country:US
Mailing Address - Phone:480-840-4777
Mailing Address - Fax:
Practice Address - Street 1:1855 S COUNTRY CLUB DR STE 111-130
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6037
Practice Address - Country:US
Practice Address - Phone:480-840-4777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty