MEDICARE: THE CENTER FOR WEIGHT LOSS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1023782406
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE CENTER FOR WEIGHT LOSS, LLC

Provider Business Mailing Address
First Line	:	536 ROYAL PECAN WAY
Second Line	:
City	:	COLLIERVILLE
State	:	TN
Zip	:	38017-1734
Country	:	US
Telephone Number	:	662-538-8009
Fax Number	:

Provider Business Practice Location Address
First Line	:	107 MAIN ST W
Second Line	:
City	:	NEW ALBANY
State	:	MS
Zip	:	38652-3324
Country	:	US
Telephone Number	:	662-534-0890
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. WILLIAM JOHNSON
Credential	:	MD
Telephone Number	:	662-538-8009

Provider Enumeration Date	:	08/09/2021
Last Update Date	:	08/09/2021

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