Healthcare Provider Details

I. General information

NPI: 1134686090
Provider Name (Legal Business Name): BELTLINE WEIGHT LOSS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2019
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

371 E PACES FERRY RD NE STE 750
ATLANTA GA
30305-2372
US

IV. Provider business mailing address

2110 POWERS FERRY RD SE STE 302
ATLANTA GA
30339-5015
US

V. Phone/Fax

Practice location:
  • Phone: 470-419-4380
  • Fax: 470-298-7736
Mailing address:
  • Phone: 470-419-4380
  • Fax: 470-298-7736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DIANA KAPOU WONG
Title or Position: COO
Credential:
Phone: 470-524-1010