=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689116832
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDI WEIGHTLOSS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2016
-----------------------------------------------------
Last Update Date | 11/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4000 FIVE POINTS BLVD., SUITE 169
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-375-0537
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4000 FIVE POINTS BLVD., SUITE 169
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-375-0537
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | IVY CASTILLO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-375-0537
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | AP131658
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------