=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841664208
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARK CITIES WEIGHTLOSS CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2015
-----------------------------------------------------
Last Update Date | 11/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6170 SHERRY LN SUITE 300
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75225-6350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-253-0029
-----------------------------------------------------
Fax | 214-466-6806
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2050 SHADY OAKS DR
-----------------------------------------------------
City | SOUTHLAKE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76092-3510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-271-4154
-----------------------------------------------------
Fax | 817-697-1595
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. STEPHEN JOEL OREN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-271-4154
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | M2243
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------