Healthcare Provider Details

I. General information

NPI: 1386576783
Provider Name (Legal Business Name): LEGACY HEALTH AND WELLNESS, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 COONROD AVE
MANNFORD OK
74044
US

IV. Provider business mailing address

154 COONROD AVE
MANNFORD OK
74044
US

V. Phone/Fax

Practice location:
  • Phone: 918-508-6992
  • Fax:
Mailing address:
  • Phone: 918-508-6992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State

VIII. Authorized Official

Name: MS. TIFFANY CAUDLE
Title or Position: APPLIED KINESIOLOGIST
Credential: APPLIED KINESIOLOGIS
Phone: 918-404-0302