Healthcare Provider Details

I. General information

NPI: 1386040186
Provider Name (Legal Business Name): NAUGATUCK VALLEY WEIGHT LOSS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2014
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 BOSTON POST RD
ORANGE CT
06477-3235
US

IV. Provider business mailing address

509 S HYDE PARK AVE
TAMPA FL
33606-2266
US

V. Phone/Fax

Practice location:
  • Phone: 203-891-0655
  • Fax: 866-581-0408
Mailing address:
  • Phone: 813-228-6334
  • Fax: 813-228-6763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JODI DESPOY
Title or Position: MANAGER
Credential:
Phone: 813-228-6334