Healthcare Provider Details

I. General information

NPI: 1235546961
Provider Name (Legal Business Name): SOUTH WELLNESS COMMUNITY HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2014
Last Update Date: 05/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

2149 SW 59TH ST
OKLAHOMA CITY OK
73119-7033
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-5860
  • Fax: 405-778-6843
Mailing address:
  • Phone: 405-271-5860
  • Fax: 405-778-6843

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: BRIAN L MADDY
Title or Position: CEO
Credential:
Phone: 405-271-3932