=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144914730
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPREHENSIVE WEIGHT MANAGEMENT CENTER LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2023
-----------------------------------------------------
Last Update Date | 06/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4747 LINCOLN MALL DR STE 100
-----------------------------------------------------
City | MATTESON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60443-3812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-747-8006
-----------------------------------------------------
Fax | 708-747-8272
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4747 LINCOLN MALL DR STE 100
-----------------------------------------------------
City | MATTESON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60443-3812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-747-8006
-----------------------------------------------------
Fax | 708-747-8272
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | SHERRIFF ALLI-BALOGUN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 708-250-5091
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------