Healthcare Provider Details

I. General information

NPI: 1639809965
Provider Name (Legal Business Name): THE BAREFOOT LOTUS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2022
Last Update Date: 06/10/2022
Certification Date: 06/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 SW A AVE STE A
LAWTON OK
73501-3932
US

IV. Provider business mailing address

621 SE 38TH ST
LAWTON OK
73501-8401
US

V. Phone/Fax

Practice location:
  • Phone: 580-917-6153
  • Fax:
Mailing address:
  • Phone: 580-917-6153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: MS. JOANN OMENGEBAR
Title or Position: OWNER/MANAGER
Credential: HHP
Phone: 580-917-6153