MEDICARE: FAIRMONT WEIGHT LOSS CLINIC 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	261Q00000X	Clinic/Center	M6-830	TX

General Provider Information

NPI Number	:	1912237702
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAIRMONT WEIGHT LOSS CLINIC LLC

Provider Business Mailing Address
First Line	:	4416 FAIRMONT PKWY STE 108
Second Line	:
City	:	PASADENA
State	:	TX
Zip	:	77504-3327
Country	:	US
Telephone Number	:	281-487-0402
Fax Number	:	281-487-0348

Provider Business Practice Location Address
First Line	:	4416 FAIRMONT PKWY STE 108
Second Line	:
City	:	PASADENA
State	:	TX
Zip	:	77504-3327
Country	:	US
Telephone Number	:	281-487-0402
Fax Number	:	281-487-0348

Authorized Official
Title or Position	:	CLINIC MANAGER
Name	:	MR. JUAN M TORRES
Credential	:
Telephone Number	:	281-487-0627

Provider Enumeration Date	:	12/30/2009
Last Update Date	:	12/30/2009

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