Healthcare Provider Details

I. General information

NPI: 1861017899
Provider Name (Legal Business Name): LASER TRIM CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2020
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 LAKE FORREST DR STE 125
ATLANTA GA
30328-3882
US

IV. Provider business mailing address

2863 95TH ST STE 225
NAPERVILLE IL
60564-9005
US

V. Phone/Fax

Practice location:
  • Phone: 404-937-6126
  • Fax: 404-341-5463
Mailing address:
  • Phone: 630-908-9509
  • Fax: 404-341-5463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RB0002X
TaxonomyObesity Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY RYAN PUA
Title or Position: PHYSICIAN
Credential: MD
Phone: 630-908-9509