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General NPI Number Information
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NPI Number | 1154965044
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Entity Type | Organization
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Legal Business Name | COMMUNITY WELLNESS CLINIC, LLC
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Dates
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Enumeration Date | 11/04/2019
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Last Update Date | 11/04/2019
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Provider Practice Location Address
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Address Line | 707 S ROLAND RD STE 6
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City | ROLAND
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State | OK
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Zip | 74954-5337
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Country | US
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Telephone | 479-221-7119
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 937
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City | ROLAND
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State | OK
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Zip | 74954-0937
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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 | PARTNER
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Name | NOEL SANGER
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Credential |
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Telephone | 816-769-1680
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208VP0000X
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Taxonomy Name | Pain Medicine Physician
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License Number |
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License Number State |
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