Healthcare Provider Details

I. General information

NPI: 1790283752
Provider Name (Legal Business Name): AFFINITY HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2018
Last Update Date: 01/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N BROADWAY ST
POTEAU OK
74953-3355
US

IV. Provider business mailing address

301 N BROADWAY ST
POTEAU OK
74953-3355
US

V. Phone/Fax

Practice location:
  • Phone: 918-208-7497
  • Fax: 918-208-7687
Mailing address:
  • Phone: 918-208-7497
  • Fax: 918-208-7687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number3982
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3982
License Number StateOK

VIII. Authorized Official

Name: RYAN PITTS
Title or Position: MEDICAL DIRECTOR
Credential: DO
Phone: 918-208-7497