Healthcare Provider Details

I. General information

NPI: 1396194965
Provider Name (Legal Business Name): WEIGHT LOSS SURGICAL INSTITUTE, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2016
Last Update Date: 06/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 E SOUTHERN AVE
TEMPE AZ
85282
US

IV. Provider business mailing address

1855 E SOUTHERN AVE
TEMPE AZ
85282
US

V. Phone/Fax

Practice location:
  • Phone: 480-829-6100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateAZ

VIII. Authorized Official

Name: THOMAS BUDDENSICK
Title or Position: PROVIDER
Credential: M.D.
Phone: 480-829-6100