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General NPI Number Information
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NPI Number | 1609061852
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Entity Type | Organization
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Legal Business Name | THE INSTITUTE OF LIFESTYLE AND WEIGHT MANAGEMENT
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Dates
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Enumeration Date | 09/11/2007
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Last Update Date | 09/11/2007
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Provider Practice Location Address
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Address Line | 3100 DURALEIGH RD SUITE 200
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City | RALEIGH
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State | NC
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Zip | 27612-8106
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Country | US
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Telephone | 919-791-1112
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Fax |
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Provider Business Mailing Address
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Address Line | 3100 DURALEIGH RD SUITE 200
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City | RALEIGH
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State | NC
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Zip | 27612-8106
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Country | US
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Telephone | 919-791-1112
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Fax |
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Authorized Official
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Title or Position | PRESIDENT AND CEO
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Name | MR. EZRA BROOKS WILKINS
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Credential | M.D.
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Telephone | 919-791-1112
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 00987496
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License Number State | NC
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