Provider Demographics
NPI:1104285980
Name:FIRST DOCTORS WEIGHT LOSS
Entity type:Organization
Organization Name:FIRST DOCTORS WEIGHT LOSS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:T.
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BLOODWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-567-5917
Mailing Address - Street 1:6794 BILL CARRUTH PKWY
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-3770
Mailing Address - Country:US
Mailing Address - Phone:678-567-5918
Mailing Address - Fax:
Practice Address - Street 1:6794 BILL CARRUTH PKWY
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-3770
Practice Address - Country:US
Practice Address - Phone:678-567-5918
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-22
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA114757261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care