Healthcare Provider Details

I. General information

NPI: 1154694537
Provider Name (Legal Business Name): THE RESTORATIVE PAIN TO WELLNESS CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2012
Last Update Date: 05/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2033 W HOUSTON ST
BROKEN ARROW OK
74012-8304
US

IV. Provider business mailing address

2033 W HOUSTON ST
BROKEN ARROW OK
74012-8304
US

V. Phone/Fax

Practice location:
  • Phone: 918-743-3636
  • Fax: 918-743-3663
Mailing address:
  • Phone: 918-743-3636
  • Fax: 918-743-3663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number4209
License Number StateOK

VIII. Authorized Official

Name: DR. JOSHUA JAMES LIVINGSTON
Title or Position: OWNER
Credential: D.O.
Phone: 918-743-3636