MEDICARE: WONDER WEIGHT LOSS AND WELLNESS CENTER

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	133N00000X	Nutritionist
2	174H00000X	Health Educator
3	208D00000X	General Practice Physician
4	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1376067215
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WONDER WEIGHT LOSS AND WELLNESS CENTER

Provider Business Mailing Address
First Line	:	11665 S HIGHWAY 6
Second Line	:
City	:	SUGAR LAND
State	:	TX
Zip	:	77498-1302
Country	:	US
Telephone Number	:	832-999-4306
Fax Number	:

Provider Business Practice Location Address
First Line	:	11665 S HIGHWAY 6
Second Line	:
City	:	SUGAR LAND
State	:	TX
Zip	:	77498-1302
Country	:	US
Telephone Number	:	832-999-4306
Fax Number	:

Authorized Official
Title or Position	:	FNP
Name	:	MERCY ABIDOYE-FAKOYA
Credential	:
Telephone Number	:	832-999-4306

Provider Enumeration Date	:	08/02/2017
Last Update Date	:	08/02/2017

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