Healthcare Provider Details

I. General information

NPI: 1578967188
Provider Name (Legal Business Name): ADVANCED MEDICAL WEIGHT LOSS RX S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2014
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 JUNCTION DR
GLEN CARBON IL
62034-4300
US

IV. Provider business mailing address

19 JUNCTION DR
GLEN CARBON IL
62034-4300
US

V. Phone/Fax

Practice location:
  • Phone: 618-655-0990
  • Fax:
Mailing address:
  • Phone: 618-655-0990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number038009646
License Number StateIL

VIII. Authorized Official

Name: DR. JOSHUA HOTTES
Title or Position: OWNER
Credential: DC
Phone: 618-655-0990