Healthcare Provider Details

I. General information

NPI: 1538673256
Provider Name (Legal Business Name): SOUTHERN OKLAHOMA LIFESTYLES AND PREVENTATIVE MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2017
Last Update Date: 11/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 12TH AVE NW STE 201
ARDMORE OK
73401-5764
US

IV. Provider business mailing address

1301 S I 35 SERVICE RD STE 106
MOORE OK
73160-3187
US

V. Phone/Fax

Practice location:
  • Phone: 405-703-3614
  • Fax:
Mailing address:
  • Phone: 405-703-3614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number StateOK

VIII. Authorized Official

Name: NIKKI BUSELLATO
Title or Position: INS. CREDENTIALING
Credential:
Phone: 405-703-3614