Healthcare Provider Details

I. General information

NPI: 1891204244
Provider Name (Legal Business Name): LAURA'S TOTAL BODY SOLUTIONS SPA TULSA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2017
Last Update Date: 09/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7127 S YALE AVE
TULSA OK
74136-6308
US

IV. Provider business mailing address

29560 S PINE VALLEY DR
CATOOSA OK
74015-6149
US

V. Phone/Fax

Practice location:
  • Phone: 918-698-1866
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LAURA JEAN WIDNEY
Title or Position: PARTNER
Credential:
Phone: 918-770-2271