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General NPI Number Information
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NPI Number | 1154198737
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Entity Type | Organization
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Legal Business Name | PWWL CENTERS, LLC
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Dates
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Enumeration Date | 12/05/2023
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Last Update Date | 12/05/2023
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Provider Practice Location Address
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Address Line | 644 STATELINE RD
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City | COLCORD
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State | OK
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Zip | 74338-1344
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Country | US
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Telephone | 918-203-0004
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 6691
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City | VAN BUREN
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State | AR
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Zip | 72956-0601
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Country | US
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Telephone | 479-459-6354
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | JERRY DALE FREDERIKSEN SR.
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Credential |
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Telephone | 479-459-6354
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QC1500X
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Taxonomy Name | Community Health Clinic/Center
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License Number |
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License Number State |
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