Provider Demographics
NPI:1588128599
Name:ADVANCED ELEGANT WEIGHT LOSS & FAMILY HEALTH CLINIC A PROFESSIONA
Entity type:Organization
Organization Name:ADVANCED ELEGANT WEIGHT LOSS & FAMILY HEALTH CLINIC A PROFESSIONA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER & PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NOSSA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-455-0122
Mailing Address - Street 1:671 S MOLLISON AVE STE B
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-6618
Mailing Address - Country:US
Mailing Address - Phone:619-841-8148
Mailing Address - Fax:858-248-8041
Practice Address - Street 1:671 S MOLLISON AVE STE B
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-6618
Practice Address - Country:US
Practice Address - Phone:619-841-8148
Practice Address - Fax:858-248-8041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-23
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty