Provider Demographics
NPI:1770807901
Name:STOCKTON MEDICAL WEIGHT LOSS CENTER INC
Entity type:Organization
Organization Name:STOCKTON MEDICAL WEIGHT LOSS CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAREN
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:PRIMACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-242-3334
Mailing Address - Street 1:1801 E. MARCH LANE
Mailing Address - Street 2:SUITE 400D
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210
Mailing Address - Country:US
Mailing Address - Phone:209-242-3334
Mailing Address - Fax:
Practice Address - Street 1:1801 E. MARCH LANE
Practice Address - Street 2:SUITE 400D
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210
Practice Address - Country:US
Practice Address - Phone:209-242-3334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STOCKTON MEDICAL WEIGHT LOSS CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG68135207RB0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity MedicineGroup - Single Specialty