=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831675396
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENLIGHTENED WEIGH WELLNESS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2018
-----------------------------------------------------
Last Update Date | 07/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22167 WESTHEIMER PKWY STE 105
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77450-8301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-305-0735
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22167 WESTHEIMER PKWY STE 105
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77450-8301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-305-0735
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPERATIONS MANAGER/ FRANCHISEE
-----------------------------------------------------
Name | MRS. DANA C COLEMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 281-305-0735
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------