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General NPI Number Information
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NPI Number | 1861017899
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Entity Type | Organization
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Legal Business Name | LASER TRIM CORP
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Dates
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Enumeration Date | 06/16/2020
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Last Update Date | 01/26/2023
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Provider Practice Location Address
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Address Line | 6100 LAKE FORREST DR STE 125
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City | ATLANTA
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State | GA
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Zip | 30328-3882
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Country | US
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Telephone | 404-937-6126
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Fax | 404-341-5463
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Provider Business Mailing Address
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Address Line | 2863 95TH ST STE 225
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City | NAPERVILLE
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State | IL
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Zip | 60564-9005
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Country | US
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Telephone | 630-908-9509
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Fax | 404-341-5463
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Authorized Official
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Title or Position | PHYSICIAN
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Name | JEFFREY RYAN PUA
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Credential | MD
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Telephone | 630-908-9509
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RB0002X
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Taxonomy Name | Obesity Medicine (Internal Medicine) Physician
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License Number |
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License Number State |
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