Provider Demographics
NPI:1457943029
Name:INDIANA MEDICAL WEIGHT LOSS & WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:INDIANA MEDICAL WEIGHT LOSS & WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:LANNY
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:BRAFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-445-5063
Mailing Address - Street 1:4536 NW BOXWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3385
Mailing Address - Country:US
Mailing Address - Phone:631-445-5063
Mailing Address - Fax:
Practice Address - Street 1:1605 CHESTER BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1610
Practice Address - Country:US
Practice Address - Phone:765-373-8253
Practice Address - Fax:765-488-0656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-05
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity MedicineGroup - Single Specialty