MEDICARE: RENEW WEIGHT LOSS MARKETING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP2300X	Primary Care Nurse Practitioner

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1174117683	OTHER	TX	FAMILY PRACTICE

General Provider Information

NPI Number	:	1316690472
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENEW WEIGHT LOSS MARKETING LLC

Provider Business Mailing Address
First Line	:	6344 CAMP BOWIE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-5408
Country	:	US
Telephone Number	:	817-409-6265
Fax Number	:

Provider Business Practice Location Address
First Line	:	6344 CAMP BOWIE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-5408
Country	:	US
Telephone Number	:	817-409-6265
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. ANDREW THOMAS LITTLE
Credential	:
Telephone Number	:	936-577-4606

Provider Enumeration Date	:	01/30/2022
Last Update Date	:	01/30/2022

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Directions to “RENEW WEIGHT LOSS MARKETING LLC ” Practice Location

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