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General NPI Number Information
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NPI Number | 1881220069
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Entity Type | Organization
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Legal Business Name | COMPLETE BALANCE WEIGHT LOSS
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Dates
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Enumeration Date | 03/19/2020
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Last Update Date | 04/14/2020
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Provider Practice Location Address
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Address Line | 16250 NORTHLAND DR STE 204
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City | SOUTHFIELD
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State | MI
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Zip | 48075-5226
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Country | US
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Telephone | 248-973-7670
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Fax |
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Provider Business Mailing Address
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Address Line | 16250 NORTHLAND DR STE 204
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City | SOUTHFIELD
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State | MI
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Zip | 48075-5226
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Country | US
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Telephone | 248-973-7670
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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. DANA LYNN BRAXTON
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Credential | PHARMD
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Telephone | 248-225-7927
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 133N00000X
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Taxonomy Name | Nutritionist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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