Provider Demographics
NPI:1295383289
Name:KETO WELLNESS AND HORMONE CLINIC
Entity Type:Organization
Organization Name:KETO WELLNESS AND HORMONE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:RESNEDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-217-2922
Mailing Address - Street 1:900 N PORTER AVE STE 212
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-6485
Mailing Address - Country:US
Mailing Address - Phone:405-217-2922
Mailing Address - Fax:405-217-2940
Practice Address - Street 1:900 N PORTER AVE STE 212
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-6485
Practice Address - Country:US
Practice Address - Phone:405-217-2922
Practice Address - Fax:405-217-2940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1316989205Medicaid