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General NPI Number Information
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NPI Number | 1154946002
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Entity Type | Organization
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Legal Business Name | NEW BODY WEIGHT LOSS CENTER LLC
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Dates
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Enumeration Date | 06/16/2020
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Last Update Date | 06/16/2020
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Provider Practice Location Address
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Address Line | 518 WASHINGTON ST
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City | JOHNSTOWN
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State | PA
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Zip | 15901-2114
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Country | US
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Telephone | 954-668-6938
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Fax |
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Provider Business Mailing Address
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Address Line | 1109 VIRGINIA AVE
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City | JOHNSTOWN
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State | PA
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Zip | 15906-2431
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CO OWNER
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Name | KELLY MODIC
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Credential |
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Telephone | 954-668-6938
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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