Healthcare Provider Details

I. General information

NPI: 1639312960
Provider Name (Legal Business Name): BODY WISE WEIGHT LOSS & AESTHETICS CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2009
Last Update Date: 04/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3921 E BASELINE RD SUITE 100
GILBERT AZ
85234-2727
US

IV. Provider business mailing address

3921 E BASELINE RD SUITE 100
GILBERT AZ
85234-2727
US

V. Phone/Fax

Practice location:
  • Phone: 480-289-5252
  • Fax: 480-776-5169
Mailing address:
  • Phone: 480-289-5252
  • Fax: 480-776-5169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number21229
License Number StateAZ

VIII. Authorized Official

Name: DR. PAUL ALAN MIKEL
Title or Position: PHYSICIAN OWNER
Credential: M.D.
Phone: 480-289-5252