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General NPI Number Information
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NPI Number | 1790152262
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Entity Type | Organization
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Legal Business Name | NEW IMAGE WEIGHT LOSS AND SPA CENTER LLC
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Dates
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Enumeration Date | 08/31/2015
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Last Update Date | 08/31/2015
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Provider Practice Location Address
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Address Line | 5678 W BROWN DEER RD
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City | BROWN DEER
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State | WI
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Zip | 53223-2356
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Country | US
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Telephone | 414-732-6132
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Fax |
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Provider Business Mailing Address
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Address Line | 5678 W BROWN DEER RD
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City | BROWN DEER
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State | WI
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Zip | 53223-2356
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Country | US
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Telephone | 414-732-6132
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | ANGELA ARYEETEY
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Credential | APNP
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Telephone | 414-732-6132
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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 | 5455-33
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License Number State | WI
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