Healthcare Provider Details

I. General information

NPI: 1154764173
Provider Name (Legal Business Name): NE WELLNESS COMMUNITY HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2013
Last Update Date: 01/06/2020
Certification Date: 01/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 NE 63RD STREET
OKLAHOMA CITY OK
73111
US

IV. Provider business mailing address

1122 NE 13TH ST ORI 274
OKLAHOMA CITY OK
73117-1039
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-5859
  • Fax:
Mailing address:
  • Phone: 405-271-1515
  • Fax: 405-271-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOHN P ZUBIALDE
Title or Position: EXECUTIVE DEAN
Credential: MD
Phone: 405-271-1515