MEDICARE: OKLAHOMA HEALTH AND WELLNESS 97

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1407327851
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OKLAHOMA HEALTH AND WELLNESS 97

Provider Business Mailing Address
First Line	:	5700 N PORTLAND AVE STE 102
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-1662
Country	:	US
Telephone Number	:	405-942-5513
Fax Number	:	405-943-1661

Provider Business Practice Location Address
First Line	:	5700 N PORTLAND AVE STE 102
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-1662
Country	:	US
Telephone Number	:	405-942-5513
Fax Number	:	405-943-1661

Authorized Official
Title or Position	:	MANAGER
Name	:	MRS. TRISHA MOORE
Credential	:
Telephone Number	:	405-942-5513

Provider Enumeration Date	:	12/11/2018
Last Update Date	:	12/11/2018

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