Healthcare Provider Details

I. General information

NPI: 1811467053
Provider Name (Legal Business Name): MISSOURI OBESITY CENTER,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2018
Last Update Date: 11/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E BROADWAY STE 160
COLUMBIA MO
65201-5821
US

IV. Provider business mailing address

5102 BEACON FALLS DR
COLUMBIA MO
65203-9056
US

V. Phone/Fax

Practice location:
  • Phone: 573-777-9917
  • Fax: 573-777-9918
Mailing address:
  • Phone: 417-988-5306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CHARLES KONTOR WIREDU
Title or Position: OWNER
Credential: MD
Phone: 417-988-5306