Healthcare Provider Details

I. General information

NPI: 1336692243
Provider Name (Legal Business Name): KJC MEDI WEIGHTLOSS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2016
Last Update Date: 09/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 SALEM ST
WAKEFIELD MA
01880-1227
US

IV. Provider business mailing address

603 SALEM ST
WAKEFIELD MA
01880-1227
US

V. Phone/Fax

Practice location:
  • Phone: 781-245-6334
  • Fax:
Mailing address:
  • Phone: 781-245-6334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number50673
License Number StateMA

VIII. Authorized Official

Name: DR. JEANNE MARIE KILP
Title or Position: MEDICAL DIRECTOR
Credential: ACOG
Phone: 781-245-6334