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General NPI Number Information
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NPI Number | 1952615957
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Entity Type | Organization
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Legal Business Name | WEIGHT AWAY
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Dates
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Enumeration Date | 08/02/2010
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Last Update Date | 08/02/2010
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Provider Practice Location Address
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Address Line | 1895 HERNDON AVE SUITE 105
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City | CLOVIS
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State | CA
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Zip | 93611
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Country | US
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Telephone | 559-297-7563
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Fax |
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Provider Business Mailing Address
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Address Line | 255 W BULLARD SUITE 109
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City | CLOVIS
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State | CA
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Zip | 93612
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Country | US
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Telephone | 559-297-7563
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Fax | 559-297-5374
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | JESSICA THACS
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Credential | M.A.
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Telephone | 559-297-7565
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133NN1002X
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Taxonomy Name | Nutrition Education Nutritionist
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License Number | 00A786030
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License Number State | CA
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