=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073865242
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXPRESS WEIGHT LOSS OF GEORGIA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2012
-----------------------------------------------------
Last Update Date | 10/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4451 ATLANTA HWY SUITE A
-----------------------------------------------------
City | LOGANVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30052-7310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-609-8446
-----------------------------------------------------
Fax | 678-436-8858
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4451 ATLANTA HWY SUITE A
-----------------------------------------------------
City | LOGANVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30052-7310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-609-8446
-----------------------------------------------------
Fax | 678-436-8858
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. THOMAS LOCKE III
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 678-609-8446
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 36409
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------