Healthcare Provider Details

I. General information

NPI: 1952739229
Provider Name (Legal Business Name): MERIDIAN WEIGHT MANAGEMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2013
Last Update Date: 10/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 23RD AVE
MERIDIAN MS
39301-3104
US

IV. Provider business mailing address

1715 23RD AVE
MERIDIAN MS
39301-3104
US

V. Phone/Fax

Practice location:
  • Phone: 601-696-6736
  • Fax: 601-696-6778
Mailing address:
  • Phone: 601-696-6736
  • Fax: 601-696-6778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number17693
License Number StateMS

VIII. Authorized Official

Name: DAVID E BONNER
Title or Position: VICE-PRESIDENT
Credential: RN
Phone: 601-696-6736