Healthcare Provider Details

I. General information

NPI: 1053287029
Provider Name (Legal Business Name): NATIVE WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2025
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1432 W BROADWAY AVE
SULPHUR OK
73086-4216
US

IV. Provider business mailing address

410 E TULSA AVE
SULPHUR OK
73086-2845
US

V. Phone/Fax

Practice location:
  • Phone: 580-359-0597
  • Fax: 580-203-3241
Mailing address:
  • Phone: 580-359-0597
  • Fax: 580-203-3241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LAKRISTA O'DELL
Title or Position: MEMBER / OWNER
Credential: RN
Phone: 580-618-1109