Healthcare Provider Details

I. General information

NPI: 1568823938
Provider Name (Legal Business Name): NORTHEAST OKLAHOMA WELLNESS CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2016
Last Update Date: 03/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E DOWNING ST
TAHLEQUAH OK
74464-3234
US

IV. Provider business mailing address

6312 E 101ST ST
TULSA OK
74137-7007
US

V. Phone/Fax

Practice location:
  • Phone: 918-456-2594
  • Fax: 918-456-3395
Mailing address:
  • Phone: 918-893-6201
  • Fax: 918-893-6202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KEVEN PARTIN
Title or Position: OWNER
Credential:
Phone: 918-893-6201