Healthcare Provider Details

I. General information

NPI: 1124719596
Provider Name (Legal Business Name): ADDICTION WELLNESS CENTER OK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2023
Last Update Date: 02/28/2025
Certification Date: 02/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 E MEMORIAL RD STE 101
OKLAHOMA CITY OK
73131-1827
US

IV. Provider business mailing address

1100 BUSINESS PKWY S STE 1
WESTMINSTER MD
21157-3048
US

V. Phone/Fax

Practice location:
  • Phone: 405-446-5714
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JESSIE COSTLEY
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 443-839-6928