Healthcare Provider Details

I. General information

NPI: 1124302302
Provider Name (Legal Business Name): NUTRITION COUNSELING CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N STONEWALL AVE AHB 1082
OKLAHOMA CITY OK
73117-1215
US

IV. Provider business mailing address

1200 N STONEWALL AVE AHB 3057
OKLAHOMA CITY OK
73117-1215
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-2866
  • Fax: 405-271-3360
Mailing address:
  • Phone: 405-271-2113
  • Fax: 405-271-1560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: MRS. PATSY ANN JOHNSON
Title or Position: ADMINISTRATIVE COORDINATOR
Credential:
Phone: 405-271-2113