Healthcare Provider Details

I. General information

NPI: 1093943219
Provider Name (Legal Business Name): MEDSHAPE WEIGHT LOSS CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 06/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7972 W THUNDERBIRD RD 106
PEORIA AZ
85381-4903
US

IV. Provider business mailing address

7972 W THUNDERBIRD RD 106
PEORIA AZ
85381-4903
US

V. Phone/Fax

Practice location:
  • Phone: 623-412-2700
  • Fax: 623-776-3065
Mailing address:
  • Phone: 623-412-2700
  • Fax: 623-776-3065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. STEPHANIE SMITH
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 480-276-3742