Healthcare Provider Details

I. General information

NPI: 1154198737
Provider Name (Legal Business Name): PWWL CENTERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2023
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

644 STATELINE RD
COLCORD OK
74338-1344
US

IV. Provider business mailing address

PO BOX 6691
VAN BUREN AR
72956-0601
US

V. Phone/Fax

Practice location:
  • Phone: 918-203-0004
  • Fax:
Mailing address:
  • Phone: 479-459-6354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JERRY DALE FREDERIKSEN SR.
Title or Position: MANAGING MEMBER
Credential:
Phone: 479-459-6354