MEDICARE: CREATE U MEDICAL WEIGHT LOSS, PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	133NN1002X	Nutrition Education Nutritionist
2	163WG0000X	General Practice Registered Nurse
3	163WI0500X	Infusion Therapy Registered Nurse
4	163WP2201X	Ambulatory Care Registered Nurse
5	163WW0000X	Wound Care Registered Nurse
6	164W00000X	Licensed Practical Nurse
7	2083B0002X	Obesity Medicine (Preventive Medicine) Physician
8	225100000X	Physical Therapist
9	225200000X	Physical Therapy Assistant
10	225700000X	Massage Therapist
11	251F00000X	Home Infusion Agency
12	261QI0500X	Infusion Therapy Clinic/Center
13	363AM0700X	Medical Physician Assistant
14	363L00000X	Nurse Practitioner
15	261QM1300X	Multi-Specialty Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1487948154	OTHER		NPI
2	1053556399	OTHER		NPI

General Provider Information

NPI Number	:	1487313102
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CREATE U MEDICAL WEIGHT LOSS, PLLC

Provider Business Mailing Address
First Line	:	400 GILEAD RD STE 651
Second Line	:
City	:	HUNTERSVILLE
State	:	NC
Zip	:	28078-6899
Country	:	US
Telephone Number	:	704-781-8170
Fax Number	:

Provider Business Practice Location Address
First Line	:	10210 HICKORYWOOD HILL AVE STE 200
Second Line	:
City	:	HUNTERSVILLE
State	:	NC
Zip	:	28078-3417
Country	:	US
Telephone Number	:	704-781-8170
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	TIFFANY JACKSON
Credential	:
Telephone Number	:	704-781-8170

Provider Enumeration Date	:	12/09/2021
Last Update Date	:	07/13/2022

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