Healthcare Provider Details

I. General information

NPI: 1679138564
Provider Name (Legal Business Name): ACCESS WELLNESS CENTER OF OKLAHOMA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3035 NW 63RD ST STE 200
OKLAHOMA CITY OK
73116-3606
US

IV. Provider business mailing address

3035 NW 63RD ST STE 200
OKLAHOMA CITY OK
73116-3606
US

V. Phone/Fax

Practice location:
  • Phone: 405-816-7735
  • Fax:
Mailing address:
  • Phone: 405-816-7735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JIM HALE
Title or Position: MANAGE MEMBER
Credential: LPC LADC-MH
Phone: 405-816-7735