Provider Demographics
NPI:1295519486
Name:PREMIER WEIGHT LOSS OF INDIANA LLC
Entity type:Organization
Organization Name:PREMIER WEIGHT LOSS OF INDIANA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIDDY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:317-523-7121
Mailing Address - Street 1:8902 N MERIDIAN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-5306
Mailing Address - Country:US
Mailing Address - Phone:317-643-4444
Mailing Address - Fax:
Practice Address - Street 1:8902 N MERIDIAN ST STE 100
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-5306
Practice Address - Country:US
Practice Address - Phone:317-643-4444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083B0002XAllopathic & Osteopathic PhysiciansPreventive MedicineObesity MedicineGroup - Single Specialty