MEDICARE: GROW WELL HEALTH LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080P0006X	Developmental - Behavioral Pediatrics Physician

General Provider Information

NPI Number	:	1598512709
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GROW WELL HEALTH LLC

Provider Business Mailing Address
First Line	:	5840 S MEMORIAL DR STE 301
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74145-9082
Country	:	US
Telephone Number	:	918-930-6689
Fax Number	:	918-921-8824

Provider Business Practice Location Address
First Line	:	5840 S MEMORIAL DR STE 301
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74145-9082
Country	:	US
Telephone Number	:	918-930-6689
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. MATTHEW CLARK
Credential	:
Telephone Number	:	918-930-6689

Provider Enumeration Date	:	05/04/2024
Last Update Date	:	01/05/2026

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Directions to “GROW WELL HEALTH LLC ” Practice Location

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