Healthcare Provider Details

I. General information

NPI: 1831595032
Provider Name (Legal Business Name): YOUR BEST LIFE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2014
Last Update Date: 11/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8010 S 101ST EAST AVE SUITE 200
TULSA OK
74133-4562
US

IV. Provider business mailing address

8010 S 101ST EAST AVE SUITE 200
TULSA OK
74133-4562
US

V. Phone/Fax

Practice location:
  • Phone: 918-893-1440
  • Fax: 918-893-1481
Mailing address:
  • Phone: 918-893-1440
  • Fax: 918-893-1481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number28027
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number28027
License Number StateOK

VIII. Authorized Official

Name: MR. FRED CARTER GLIDEWELL
Title or Position: OWNER
Credential:
Phone: 918-893-1440