Healthcare Provider Details

I. General information

NPI: 1043096761
Provider Name (Legal Business Name): ONLINE CONTROLLED KRAVINGS WEIGHT LOSS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2023
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21701 W 11 MILE RD STE 5
SOUTHFIELD MI
48076-3713
US

IV. Provider business mailing address

21701 W 11 MILE RD STE 5
SOUTHFIELD MI
48076-3713
US

V. Phone/Fax

Practice location:
  • Phone: 248-429-9556
  • Fax:
Mailing address:
  • Phone: 248-429-9556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ZAKARI TATA
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 248-429-9556