=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649852013
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WISE WEIGHT MANAGEMENT PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2021
-----------------------------------------------------
Last Update Date | 04/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3069 BAY PLAZA DRIVE
-----------------------------------------------------
City | SAGINAW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-272-3215
-----------------------------------------------------
Fax | 833-974-2434
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6412
-----------------------------------------------------
City | SAGINAW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-272-3215
-----------------------------------------------------
Fax | 833-974-2434
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO, OWNER
-----------------------------------------------------
Name | DR. DAFINA WISE ALLEN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 989-272-3215
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QB0002X
-----------------------------------------------------
Taxonomy Name | Obesity Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------