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General NPI Number Information
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NPI Number | 1538673256
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Entity Type | Organization
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Legal Business Name | SOUTHERN OKLAHOMA LIFESTYLES AND PREVENTATIVE MEDICINE
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Dates
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Enumeration Date | 11/17/2017
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Last Update Date | 11/17/2017
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Provider Practice Location Address
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Address Line | 731 12TH AVE NW STE 201
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City | ARDMORE
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State | OK
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Zip | 73401-5764
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Country | US
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Telephone | 405-703-3614
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Fax |
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Provider Business Mailing Address
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Address Line | 1301 S I 35 SERVICE RD STE 106
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City | MOORE
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State | OK
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Zip | 73160-3187
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Country | US
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Telephone | 405-703-3614
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Fax |
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Authorized Official
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Title or Position | INS. CREDENTIALING
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Name | NIKKI BUSELLATO
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Credential |
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Telephone | 405-703-3614
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2083P0901X
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Taxonomy Name | Public Health & General Preventive Medicine Physician
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License Number |
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License Number State | OK
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