Healthcare Provider Details

I. General information

NPI: 1104267111
Provider Name (Legal Business Name): PREMIER AGE MANAGEMENT AND MEDICAL WEIGHT LOSS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2013
Last Update Date: 07/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 WARD CIR A-23
BRENTWOOD TN
37027-7518
US

IV. Provider business mailing address

229 WARD CIR A-23
BRENTWOOD TN
37027-7518
US

V. Phone/Fax

Practice location:
  • Phone: 615-649-9600
  • Fax: 615-649-9601
Mailing address:
  • Phone: 615-649-9600
  • Fax: 615-649-9601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code132700000X
TaxonomyDietary Manager
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateTN
# 9
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateTN
# 10
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM RYAN WALKER
Title or Position: ADMINISTRATIVE DIRECTOR
Credential: ESQ.
Phone: 615-649-9600