Provider Demographics
NPI:1912237702
Name:FAIRMONT WEIGHT LOSS CLINIC LLC
Entity type:Organization
Organization Name:FAIRMONT WEIGHT LOSS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:TORRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-487-0627
Mailing Address - Street 1:4416 FAIRMONT PKWY STE 108
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77504-3327
Mailing Address - Country:US
Mailing Address - Phone:281-487-0402
Mailing Address - Fax:281-487-0348
Practice Address - Street 1:4416 FAIRMONT PKWY STE 108
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77504-3327
Practice Address - Country:US
Practice Address - Phone:281-487-0402
Practice Address - Fax:281-487-0348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-30
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM6-830261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center