=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316477821
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAN ANTONIO WEIGHTLOSS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11212 STATE HIGHWAY 151 STE 210
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78251-4501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-225-1051
-----------------------------------------------------
Fax | 813-224-0610
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11212 STATE HIGHWAY 151 STE 210
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78251-4501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-225-1051
-----------------------------------------------------
Fax | 813-224-0610
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TOM WILLETT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 813-225-1051
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------