Provider Demographics
NPI:1285875039
Name:MEDSHAPE WEIGHT LOSS CLINIC LLC
Entity type:Organization
Organization Name:MEDSHAPE WEIGHT LOSS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-413-9000
Mailing Address - Street 1:1845 S DOBSON RD
Mailing Address - Street 2:202
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-5661
Mailing Address - Country:US
Mailing Address - Phone:480-413-9000
Mailing Address - Fax:480-413-2060
Practice Address - Street 1:1845 S DOBSON RD
Practice Address - Street 2:202
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-5661
Practice Address - Country:US
Practice Address - Phone:480-413-9000
Practice Address - Fax:480-413-2060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-07
Last Update Date:2009-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center