Provider Demographics
NPI:1104267111
Name:PREMIER AGE MANAGEMENT AND MEDICAL WEIGHT LOSS CENTER, LLC
Entity type:Organization
Organization Name:PREMIER AGE MANAGEMENT AND MEDICAL WEIGHT LOSS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:615-649-9600
Mailing Address - Street 1:229 WARD CIR
Mailing Address - Street 2:A-23
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7518
Mailing Address - Country:US
Mailing Address - Phone:615-649-9600
Mailing Address - Fax:615-649-9601
Practice Address - Street 1:229 WARD CIR
Practice Address - Street 2:A-23
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-7518
Practice Address - Country:US
Practice Address - Phone:615-649-9600
Practice Address - Fax:615-649-9601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
132700000X, 133N00000X, 207Q00000X, 2083P0011X, 2083P0901X, 2083S0010X, 208D00000X, 261Q00000X
TN363A00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No132700000XDietary & Nutritional Service ProvidersDietary ManagerGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty