Healthcare Provider Details

I. General information

NPI: 1285084939
Provider Name (Legal Business Name): ELEMENTAL WEIGHT LOSS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 12/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9150 HUEBNER RD STE 160
SAN ANTONIO TX
78240-1558
US

IV. Provider business mailing address

9150 HUEBNER RD STE 160
SAN ANTONIO TX
78240-1558
US

V. Phone/Fax

Practice location:
  • Phone: 210-960-2639
  • Fax: 210-845-1832
Mailing address:
  • Phone: 210-960-2639
  • Fax: 210-845-1832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberN1222
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MEGAN ROSE-LEE WILLIAMS KHMELEV
Title or Position: PRESIDENT
Credential: MD
Phone: 210-960-2639