Healthcare Provider Details

I. General information

NPI: 1306283718
Provider Name (Legal Business Name): POUNDS MEDICAL WEIGHT LOSS TRANSFORMATION PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2013
Last Update Date: 08/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 LASALLE RD STE 208
WEST HARTFORD CT
06107-2322
US

IV. Provider business mailing address

125 LASALLE RD STE 208
WEST HARTFORD CT
06107-2322
US

V. Phone/Fax

Practice location:
  • Phone: 860-906-1732
  • Fax: 860-906-1269
Mailing address:
  • Phone: 860-906-1732
  • Fax: 860-906-1269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number042274
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number042274
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code207VB0002X
TaxonomyObesity Medicine (Obstetrics & Gynecology) Physician
License Number042274
License Number StateCT

VIII. Authorized Official

Name: DR. CHARLES CAVO
Title or Position: OWNER
Credential: D.O.
Phone: 860-906-1732