Provider Demographics
NPI:1811467053
Name:MISSOURI OBESITY CENTER,LLC
Entity type:Organization
Organization Name:MISSOURI OBESITY CENTER,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:KONTOR
Authorized Official - Last Name:WIREDU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-988-5306
Mailing Address - Street 1:5102 BEACON FALLS DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-9056
Mailing Address - Country:US
Mailing Address - Phone:417-988-5306
Mailing Address - Fax:
Practice Address - Street 1:1601 E BROADWAY STE 160
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-5821
Practice Address - Country:US
Practice Address - Phone:573-777-9917
Practice Address - Fax:573-777-9918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty