Healthcare Provider Details

I. General information

NPI: 1316123912
Provider Name (Legal Business Name): FOUNDATION WEIGHTWISE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2008
Last Update Date: 01/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 RENAISSANCE BLVD SECOND FLOOR
EDMOND OK
73013-3023
US

IV. Provider business mailing address

1800 RENAISSANCE BLVD SECOND FLOOR
EDMOND OK
73013-3023
US

V. Phone/Fax

Practice location:
  • Phone: 405-359-2473
  • Fax: 405-359-2499
Mailing address:
  • Phone: 405-359-2473
  • Fax: 405-359-2499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT MORTON BYERS
Title or Position: PRESIDENT / COO
Credential:
Phone: 405-608-1700