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General NPI Number Information
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NPI Number | 1710342241
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Entity Type | Organization
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Legal Business Name | SOUTHLAKE WEIGHT LOSS, LLC
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Dates
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Enumeration Date | 12/29/2015
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Last Update Date | 12/29/2015
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Provider Practice Location Address
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Address Line | 601 E SOUTHLAKE BLVD SUITE 200
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City | SOUTHLAKE
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State | TX
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Zip | 76092-6251
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Country | US
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Telephone | 817-488-1956
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Fax | 817-488-8675
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Provider Business Mailing Address
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Address Line | 2050 SHADY OAKS DR
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City | SOUTHLAKE
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State | TX
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Zip | 76092-3510
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Country | US
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Telephone | 817-271-4154
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Fax | 817-796-1595
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MR. STEPHEN JOEL OREN
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Credential |
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Telephone | 817-271-4154
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | E4781
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License Number State | TX
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