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General NPI Number Information
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NPI Number | 1124719596
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Entity Type | Organization
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Legal Business Name | ADDICTION WELLNESS CENTER OK LLC
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Dates
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Enumeration Date | 05/17/2023
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Last Update Date | 02/28/2025
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Provider Practice Location Address
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Address Line | 1800 E MEMORIAL RD STE 101
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City | OKLAHOMA CITY
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State | OK
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Zip | 73131-1827
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Country | US
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Telephone | 405-446-5714
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Fax |
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Provider Business Mailing Address
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Address Line | 1100 BUSINESS PKWY S STE 1
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City | WESTMINSTER
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State | MD
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Zip | 21157-3048
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING SPECIALIST
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Name | JESSIE COSTLEY
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Credential |
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Telephone | 443-839-6928
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number |
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License Number State |
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