Provider Demographics
NPI:1962736348
Name:FAMILY MEDICINE & WEIGHT MANAGEMENT SPECIALTY, P.L.L.C.
Entity type:Organization
Organization Name:FAMILY MEDICINE & WEIGHT MANAGEMENT SPECIALTY, P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:SORENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-431-1152
Mailing Address - Street 1:2189 S. AVENUE A, SUITE A
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-8880
Mailing Address - Country:US
Mailing Address - Phone:928-276-4381
Mailing Address - Fax:928-276-9086
Practice Address - Street 1:2222 S AVENUE A
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-8315
Practice Address - Country:US
Practice Address - Phone:928-276-4381
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4158207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ178594OtherMEDICARE PTAN FOR STATEOF ARIZONA