Healthcare Provider Details

I. General information

NPI: 1811187800
Provider Name (Legal Business Name): FIRST CHOICE WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 N MAIN
KINGSTON OK
73439-7343
US

IV. Provider business mailing address

PO BOX 849
TISHOMINGO OK
73460-0849
US

V. Phone/Fax

Practice location:
  • Phone: 158-056-4050
  • Fax: 580-564-0500
Mailing address:
  • Phone: 580-564-0500
  • Fax: 580-564-0250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License NumberR0067529
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7588
License Number StateOK

VIII. Authorized Official

Name: ADDIE BETH GRATZ
Title or Position: OWNER
Credential: ARNP
Phone: 580-371-0500