Healthcare Provider Details

I. General information

NPI: 1114356029
Provider Name (Legal Business Name): FORWARD MEDICAL WEIGHT LOSS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2013
Last Update Date: 11/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N112W15568 MEQUON RD # 6
GERMANTOWN WI
53022-3413
US

IV. Provider business mailing address

N112W15568 MEQUON RD # 6
GERMANTOWN WI
53022-3413
US

V. Phone/Fax

Practice location:
  • Phone: 262-313-8375
  • Fax: 262-255-1482
Mailing address:
  • Phone: 262-313-8375
  • Fax: 262-255-1482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number3690-033
License Number StateWI

VIII. Authorized Official

Name: LINDSAY ANN CARMODY
Title or Position: APNP
Credential: APNP
Phone: 414-350-6807