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General NPI Number Information
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NPI Number | 1548646052
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Entity Type | Organization
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Legal Business Name | NEXT GENERATION FAMILY MEDICAL CLINIC, LLC
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Dates
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Enumeration Date | 08/06/2015
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Last Update Date | 02/22/2016
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Provider Practice Location Address
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Address Line | 1102 W CHEROKEE ST STE A
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City | WAGONER
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State | OK
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Zip | 74467-4600
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Country | US
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Telephone | 918-201-4502
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Fax | 918-201-4503
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Provider Business Mailing Address
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Address Line | 1102 W CHEROKEE ST STE A
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City | WAGONER
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State | OK
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Zip | 74467-4600
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Country | US
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Telephone | 918-201-4502
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Fax | 918-201-4503
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHELE BUCHOLTZ
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Credential | D.O.,PH.D
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Telephone | 918-201-4502
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 4383
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License Number State | OK
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