Provider Demographics
NPI:1932748829
Name:SHAPE SHIFTERS WEIGHT LOSS AND JOINT CENTER
Entity type:Organization
Organization Name:SHAPE SHIFTERS WEIGHT LOSS AND JOINT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:BYRD
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:423-335-3077
Mailing Address - Street 1:104 UNIVERSITY PKWY STE 1
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-7349
Mailing Address - Country:US
Mailing Address - Phone:423-335-3077
Mailing Address - Fax:
Practice Address - Street 1:104 UNIVERSITY PKWY STE 1
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-7349
Practice Address - Country:US
Practice Address - Phone:423-335-3077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-26
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty