Healthcare Provider Details

I. General information

NPI: 1982101309
Provider Name (Legal Business Name): ESSEX COUNTY WEIGHTLOSS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2018
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 STATE ROAD 10 EAST
RANDOLPH NJ
07869
US

IV. Provider business mailing address

81 STATE ROAD 10 EAST
RANDOLPH NJ
07869
US

V. Phone/Fax

Practice location:
  • Phone: 973-891-1870
  • Fax:
Mailing address:
  • Phone: 973-891-1870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JODI DESPOY
Title or Position: MANAGER
Credential:
Phone: 813-228-6334