=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518736149
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOTAL BODY RENEWAL MEDICAL WEIGHT MANAGEMENT & LASER TREATMENT CENTE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2023
-----------------------------------------------------
Last Update Date | 07/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 420 COLUMBIA CTR
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62236-2540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-719-2011
-----------------------------------------------------
Fax | 618-417-6046
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10400 ADRIAN RD
-----------------------------------------------------
City | MASCOUTAH
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62258-4344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-967-9859
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KELLY ANN WOOD
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 618-967-9859
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------