Organization
DIVA WEIGHT LOSS LLC
Active
Other names
b/ba Performance Weight Loss and MediSpa
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. CARYN ALISON JOHNSON CFNP (OWNER)
(601) 624-5840
Entity
Organization
Contact information
Practice address
604 GOODRIDGE DR, SUITE A, RIDGELAND, MS 39157-4402
(769) 251-1040
Mailing address
604 GOODRIDGE DR, SUITE A, RIDGELAND, MS 39157-4402
(769) 251-1040
Taxonomy
Speciality
Code
Description
License number
State
261QH0100X
Health Service Clinic/Center
Primary
R869964
MS
Other
Enumeration date
09/20/2011
Last updated
02/13/2012
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