Healthcare Provider Details

I. General information

NPI: 1609230721
Provider Name (Legal Business Name): SAN ANTONIO WEIGHTLOSS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 04/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11703 HUEBNER RD SUITE 100
SAN ANTONIO TX
78230-1201
US

IV. Provider business mailing address

412 E MADISON ST SUITE 1100
TAMPA FL
33602-4601
US

V. Phone/Fax

Practice location:
  • Phone: 210-697-9500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: THOMAS K WILLETT
Title or Position: MANAGING MEMBER
Credential:
Phone: 813-225-1051