Healthcare Provider Details

I. General information

NPI: 1841663366
Provider Name (Legal Business Name): NEW IMAGE WEIGHT LOSS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2015
Last Update Date: 11/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1956 RAINBOW DR
GADSDEN AL
35901-5567
US

IV. Provider business mailing address

1956 RAINBOW DR
GADSDEN AL
35901-5567
US

V. Phone/Fax

Practice location:
  • Phone: 256-438-5839
  • Fax: 256-467-3130
Mailing address:
  • Phone: 256-438-5839
  • Fax: 256-467-3130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code132700000X
TaxonomyDietary Manager
License Number905
License Number StateAL

VIII. Authorized Official

Name: MRS. JENNIFER THRASHER
Title or Position: OWNER
Credential:
Phone: 256-438-5839