Healthcare Provider Details

I. General information

NPI: 1902437346
Provider Name (Legal Business Name): MED SPA AT ENID LIVE WELL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2020
Last Update Date: 11/11/2020
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 N VAN BUREN ST
ENID OK
73703-2524
US

IV. Provider business mailing address

2111 N VAN BUREN ST
ENID OK
73703-2524
US

V. Phone/Fax

Practice location:
  • Phone: 580-233-4300
  • Fax: 580-350-6401
Mailing address:
  • Phone: 580-233-4300
  • Fax: 580-350-6401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. VIKI SHARLAIN WHITE
Title or Position: CEO
Credential: DC
Phone: 580-233-4300