Healthcare Provider Details

I. General information

NPI: 1497263818
Provider Name (Legal Business Name): TRANSFORMATION HEALTH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2018
Last Update Date: 11/08/2022
Certification Date: 11/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12142 S YUKON AVE
GLENPOOL OK
74033
US

IV. Provider business mailing address

12142 S YUKON AVE
GLENPOOL OK
74033
US

V. Phone/Fax

Practice location:
  • Phone: 918-935-3636
  • Fax: 918-296-7934
Mailing address:
  • Phone: 918-935-3636
  • Fax: 918-296-7934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHAD EDWARDS
Title or Position: OWNER
Credential: DO
Phone: 918-935-3636