Healthcare Provider Details

I. General information

NPI: 1790695153
Provider Name (Legal Business Name): LAN WANG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MASSAGE MIRACLE LLC

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/13/2026
Certification Date: 09/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6505 S ELM PL
BROKEN ARROW OK
74011-6629
US

IV. Provider business mailing address

11742 S REDBUD ST
JENKS OK
74037-4319
US

V. Phone/Fax

Practice location:
  • Phone: 918-907-8881
  • Fax:
Mailing address:
  • Phone: 918-350-6809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number182761
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: