Basic Information
Provider Information | |||||||||
NPI: | 1457621799 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MOORESVILLE PPM LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | THE CENTER FOR SURGICAL WEIGHT LOSS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4000 MERIDIAN BLVD | ||||||||
Address2: |   | ||||||||
City: | FRANKLIN | ||||||||
State: | TN | ||||||||
PostalCode: | 370676325 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6154657230 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 131 MEDICAL PARK RD | ||||||||
Address2: | SUITE 303 | ||||||||
City: | MOORESVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 281178522 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7046604584 | ||||||||
FaxNumber: | 7046604967 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/04/2012 | ||||||||
LastUpdateDate: | 01/14/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JACKSON | ||||||||
AuthorizedOfficialFirstName: | JENNIFER | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | SR DIR PROV ENROLLMENT & ONBOARDING | ||||||||
AuthorizedOfficialTelephone: | 6154653334 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MOORESVILLE PPM LLC | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/14/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.