MEDICARE: WEIGHT LOSS & WELLNESS CLINIC

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	261QM1300X	Multi-Specialty Clinic/Center	261AM1300X	NC

General Provider Information

NPI Number	:	1689876021
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEIGHT LOSS & WELLNESS CLINIC

Provider Business Mailing Address
First Line	:	16507 NORTHCROSS DR STE F
Second Line	:
City	:	HUNTERSVILLE
State	:	NC
Zip	:	28078-5082
Country	:	US
Telephone Number	:	704-728-7283
Fax Number	:

Provider Business Practice Location Address
First Line	:	16507 NORTHCROSS DR STE F
Second Line	:
City	:	HUNTERSVILLE
State	:	NC
Zip	:	28078-5082
Country	:	US
Telephone Number	:	704-728-7283
Fax Number	:

Authorized Official
Title or Position	:	BUSINESS ADMINISTRATOR
Name	:	DEBORAH E BAIRD
Credential	:
Telephone Number	:	704-728-7283

Provider Enumeration Date	:	06/05/2007
Last Update Date	:	08/22/2020

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