MEDICARE: MISSOURI OBESITY CENTER,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	207RE0101X	Endocrinology, Diabetes & Metabolism Physician

General Provider Information

NPI Number	:	1811467053
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSOURI OBESITY CENTER,LLC

Provider Business Mailing Address
First Line	:	5102 BEACON FALLS DR
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65203-9056
Country	:	US
Telephone Number	:	417-988-5306
Fax Number	:

Provider Business Practice Location Address
First Line	:	1601 E BROADWAY STE 160
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65201-5821
Country	:	US
Telephone Number	:	573-777-9917
Fax Number	:	573-777-9918

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CHARLES KONTOR WIREDU
Credential	:	MD
Telephone Number	:	417-988-5306

Provider Enumeration Date	:	11/30/2018
Last Update Date	:	11/30/2018

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