Healthcare Provider Details

I. General information

NPI: 1386199826
Provider Name (Legal Business Name): KENNETH WILLS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2016
Last Update Date: 08/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 N FOREST RIDGE BLVD
BROKEN ARROW OK
74014-2758
US

IV. Provider business mailing address

416 N FOREST RIDGE BLVD
BROKEN ARROW OK
74014-2758
US

V. Phone/Fax

Practice location:
  • Phone: 918-698-9246
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: