=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033697560
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TULSA HEALTH AND WELLNESS MEDICAL CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2018
-----------------------------------------------------
Last Update Date | 03/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4845 S SHERIDAN RD STE 411
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74145-5751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-641-4531
-----------------------------------------------------
Fax | 918-641-4717
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4845 S SHERIDAN RD STE 411
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74145-5751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-574-1775
-----------------------------------------------------
Fax | 918-641-4717
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DUSTIN SHEHAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 918-574-1775
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------