Provider Demographics
NPI:1154946002
Name:NEW BODY WEIGHT LOSS CENTER LLC
Entity type:Organization
Organization Name:NEW BODY WEIGHT LOSS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MODIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-668-6938
Mailing Address - Street 1:1109 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15906-2431
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:518 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15901-2114
Practice Address - Country:US
Practice Address - Phone:954-668-6938
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-16
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty