MEDICARE: PBA WELLNESS,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	133V00000X	Registered Dietitian	1678	OK

General Provider Information

NPI Number	:	1619304847
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PBA WELLNESS,LLC

Provider Business Mailing Address
First Line	:	4775 E 91ST ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74137-2801
Country	:	US
Telephone Number	:	918-496-2000
Fax Number	:	918-496-2338

Provider Business Practice Location Address
First Line	:	4775 E 91ST ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74137-2801
Country	:	US
Telephone Number	:	918-496-2000
Fax Number	:	918-496-2338

Authorized Official
Title or Position	:	DIETITIAN
Name	:	ELIZABETH CHRISTINE MILLER
Credential	:	RD/LD
Telephone Number	:	918-551-7901

Provider Enumeration Date	:	10/02/2013
Last Update Date	:	10/02/2013

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