Provider Demographics
NPI:1235546961
Name:SOUTH WELLNESS COMMUNITY HEALTH CLINIC
Entity Type:Organization
Organization Name:SOUTH WELLNESS COMMUNITY HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MADDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-271-3932
Mailing Address - Street 1:2149 SW 59TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73119-7033
Mailing Address - Country:US
Mailing Address - Phone:405-271-5860
Mailing Address - Fax:405-778-6843
Practice Address - Street 1:1122 NE 13TH ST
Practice Address - Street 2:ORI 274
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-1039
Practice Address - Country:US
Practice Address - Phone:405-271-5860
Practice Address - Fax:405-778-6843
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOARD OF REGENTS OF THE UNIVERSITY OF OKLAHOMA-OU PHYSICIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-15
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health