MEDICARE: LAURA'S TOTAL BODY SOLUTIONS SPA TULSA 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	2083B0002X	Obesity Medicine (Preventive Medicine) Physician
2	2083P0901X	Public Health & General Preventive Medicine Physician

General Provider Information

NPI Number	:	1891204244
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAURA'S TOTAL BODY SOLUTIONS SPA TULSA LLC

Provider Business Mailing Address
First Line	:	29560 S PINE VALLEY DR
Second Line	:
City	:	CATOOSA
State	:	OK
Zip	:	74015-6149
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7127 S YALE AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74136-6308
Country	:	US
Telephone Number	:	918-698-1866
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	LAURA JEAN WIDNEY
Credential	:
Telephone Number	:	918-770-2271

Provider Enumeration Date	:	09/28/2017
Last Update Date	:	09/28/2017

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