MEDICARE: DOCTORS WEIGHT LOSS CENTER & WELLNESS

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	364SA2200X	Adult Health Clinical Nurse Specialist	736533	TX

General Provider Information

NPI Number	:	1063852069
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOCTORS WEIGHT LOSS CENTER & WELLNESS

Provider Business Mailing Address
First Line	:	11215 S INTERSTATE 35
Second Line	:	SUITE 114
City	:	AUSTIN
State	:	TX
Zip	:	78747-1863
Country	:	US
Telephone Number	:	512-782-2084
Fax Number	:	512-782-2088

Provider Business Practice Location Address
First Line	:	11215 S INTERSTATE 35
Second Line	:	SUITE 114
City	:	AUSTIN
State	:	TX
Zip	:	78747-1863
Country	:	US
Telephone Number	:	512-782-2084
Fax Number	:	512-782-2088

Authorized Official
Title or Position	:	MANAGING PARNER
Name	:	MRS. ADYS MIRABAL
Credential	:	VICE PRESIDENT
Telephone Number	:	512-782-2084

Provider Enumeration Date	:	07/05/2013
Last Update Date	:	07/05/2013

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