Healthcare Provider Details

I. General information

NPI: 1841664208
Provider Name (Legal Business Name): PARK CITIES WEIGHTLOSS CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2015
Last Update Date: 11/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6170 SHERRY LN SUITE 300
DALLAS TX
75225-6350
US

IV. Provider business mailing address

2050 SHADY OAKS DR
SOUTHLAKE TX
76092-3510
US

V. Phone/Fax

Practice location:
  • Phone: 214-253-0029
  • Fax: 214-466-6806
Mailing address:
  • Phone: 817-271-4154
  • Fax: 817-697-1595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM2243
License Number StateTX

VIII. Authorized Official

Name: MR. STEPHEN JOEL OREN
Title or Position: PRESIDENT
Credential:
Phone: 817-271-4154