Provider Demographics
NPI:1043096761
Name:ONLINE CONTROLLED KRAVINGS WEIGHT LOSS PLLC
Entity type:Organization
Organization Name:ONLINE CONTROLLED KRAVINGS WEIGHT LOSS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ZAKARI
Authorized Official - Middle Name:
Authorized Official - Last Name:TATA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-429-9556
Mailing Address - Street 1:21701 W 11 MILE RD STE 5
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-3713
Mailing Address - Country:US
Mailing Address - Phone:248-429-9556
Mailing Address - Fax:
Practice Address - Street 1:21701 W 11 MILE RD STE 5
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-3713
Practice Address - Country:US
Practice Address - Phone:248-429-9556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ONLINE CONTROLLED KRAVINGS WEIGHT LOSS PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty