Healthcare Provider Details

I. General information

NPI: 1518736149
Provider Name (Legal Business Name): TOTAL BODY RENEWAL MEDICAL WEIGHT MANAGEMENT & LASER TREATMENT CENTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2023
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 COLUMBIA CTR
COLUMBIA IL
62236-2540
US

IV. Provider business mailing address

10400 ADRIAN RD
MASCOUTAH IL
62258-4344
US

V. Phone/Fax

Practice location:
  • Phone: 618-719-2011
  • Fax: 618-417-6046
Mailing address:
  • Phone: 618-967-9859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KELLY ANN WOOD
Title or Position: OWNER
Credential: MD
Phone: 618-967-9859