Healthcare Provider Details

I. General information

NPI: 1952615957
Provider Name (Legal Business Name): WEIGHT AWAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2010
Last Update Date: 08/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1895 HERNDON AVE SUITE 105
CLOVIS CA
93611
US

IV. Provider business mailing address

255 W BULLARD SUITE 109
CLOVIS CA
93612
US

V. Phone/Fax

Practice location:
  • Phone: 559-297-7563
  • Fax:
Mailing address:
  • Phone: 559-297-7563
  • Fax: 559-297-5374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number00A786030
License Number StateCA

VIII. Authorized Official

Name: JESSICA THACS
Title or Position: OFFICE MANAGER
Credential: M.A.
Phone: 559-297-7565