Provider Demographics
NPI:1730607870
Name:KING'S WILLNESS AND WEIGHT LOSS CENTERS LLC
Entity type:Organization
Organization Name:KING'S WILLNESS AND WEIGHT LOSS CENTERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-BC
Authorized Official - Phone:304-252-3900
Mailing Address - Street 1:615 MARKET RD
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-9445
Mailing Address - Country:US
Mailing Address - Phone:304-252-3900
Mailing Address - Fax:304-252-9311
Practice Address - Street 1:615 MARKET RD
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-9445
Practice Address - Country:US
Practice Address - Phone:304-252-3900
Practice Address - Fax:304-252-9311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-08
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV49327363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV71020690000Medicaid