Healthcare Provider Details

I. General information

NPI: 1477359016
Provider Name (Legal Business Name): AGAFAY WEIGHT LOSS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2025
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10420 OLD OLIVE STREET RD STE 100
SAINT LOUIS MO
63141-5937
US

IV. Provider business mailing address

10420 OLD OLIVE STREET RD STE 100
SAINT LOUIS MO
63141-5937
US

V. Phone/Fax

Practice location:
  • Phone: 314-914-4833
  • Fax:
Mailing address:
  • Phone: 314-914-4833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: PENINNAH MUTUNGI
Title or Position: MD/OWNER
Credential: MD
Phone: 401-787-8864