Organization
BIG BLUE STAR LLC
Active
Other names
WeightWise
Organization subpart
No
Provider details
NPI number
Authorized official
DR. TOBY DANIEL BROUSSARD MD (CO OWNER)
(405) 974-8412
Entity
Organization
Contact information
Practice address
1800 RENAISSANCE BLVD STE 200, EDMOND, OK 73013-3023
(404) 359-2473
Mailing address
1800 RENAISSANCE BLVD STE 200, EDMOND, OK 73013-3023
(404) 359-2473
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
Primary
—
—
174400000X
Specialist
—
—
208600000X
Surgery Physician
—
—
291U00000X
Clinical Medical Laboratory
—
—
Other
Enumeration date
11/12/2009
Last updated
12/17/2009
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