MEDICARE: SAN ANTONIO WEIGHTLOSS 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	207QB0002X	Obesity Medicine (Family Medicine) Physician

General Provider Information

NPI Number	:	1609230721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN ANTONIO WEIGHTLOSS LLC

Provider Business Mailing Address
First Line	:	412 E MADISON ST
Second Line	:	SUITE 1100
City	:	TAMPA
State	:	FL
Zip	:	33602-4601
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11703 HUEBNER RD
Second Line	:	SUITE 100
City	:	SAN ANTONIO
State	:	TX
Zip	:	78230-1201
Country	:	US
Telephone Number	:	210-697-9500
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	THOMAS K WILLETT
Credential	:
Telephone Number	:	813-225-1051

Provider Enumeration Date	:	04/06/2016
Last Update Date	:	04/06/2016

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