Healthcare Provider Details

I. General information

NPI: 1558258285
Provider Name (Legal Business Name): LIVEWELL HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2025
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 HARRIS CIR STE 102
TAHLEQUAH OK
74464-8849
US

IV. Provider business mailing address

PO BOX 688
STILWELL OK
74960-0688
US

V. Phone/Fax

Practice location:
  • Phone: 719-214-0270
  • Fax:
Mailing address:
  • Phone: 719-214-0270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier1831176924
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerNPI

VIII. Authorized Official

Name: JASON MORGAN
Title or Position: CEO
Credential: PA
Phone: 719-214-0270