Provider Demographics
NPI:1841492709
Name:CENTER FOR WEIGHT MANAGEMENT
Entity type:Organization
Organization Name:CENTER FOR WEIGHT MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN
Authorized Official - Phone:586-759-7469
Mailing Address - Street 1:13355 E. TEN MILE RD.
Mailing Address - Street 2:SUITE CHM
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-2065
Mailing Address - Country:US
Mailing Address - Phone:586-759-7457
Mailing Address - Fax:
Practice Address - Street 1:13355 E. TEN MILE RD.
Practice Address - Street 2:SUITE CHM
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-2065
Practice Address - Country:US
Practice Address - Phone:586-759-7457
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIVS080188174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty