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General NPI Number Information
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NPI Number | 1457943029
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Entity Type | Organization
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Legal Business Name | INDIANA MEDICAL WEIGHT LOSS & WELLNESS CENTER LLC
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Dates
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Enumeration Date | 02/05/2021
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Last Update Date | 12/02/2021
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Provider Practice Location Address
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Address Line | 1605 CHESTER BLVD
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City | RICHMOND
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State | IN
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Zip | 47374-1610
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Country | US
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Telephone | 765-373-8253
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Fax | 765-488-0656
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Provider Business Mailing Address
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Address Line | 4536 NW BOXWOOD DR
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City | CORVALLIS
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State | OR
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Zip | 97330-3385
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Country | US
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Telephone | 631-445-5063
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | MR. LANNY JAY BRAFF
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Credential |
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Telephone | 631-445-5063
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RB0002X
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Taxonomy Name | Obesity Medicine (Internal Medicine) Physician
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License Number |
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License Number State |
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