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General NPI Number Information
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NPI Number | 1811467053
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Entity Type | Organization
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Legal Business Name | MISSOURI OBESITY CENTER,LLC
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Dates
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Enumeration Date | 11/30/2018
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Last Update Date | 11/30/2018
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Provider Practice Location Address
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Address Line | 1601 E BROADWAY STE 160
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City | COLUMBIA
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State | MO
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Zip | 65201-5821
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Country | US
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Telephone | 573-777-9917
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Fax | 573-777-9918
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Provider Business Mailing Address
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Address Line | 5102 BEACON FALLS DR
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City | COLUMBIA
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State | MO
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Zip | 65203-9056
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Country | US
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Telephone | 417-988-5306
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. CHARLES KONTOR WIREDU
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Credential | MD
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Telephone | 417-988-5306
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RE0101X
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Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
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License Number |
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License Number State |
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