Provider Demographics
NPI:1336690379
Name:ABUNDANT WELLNESS
Entity Type:Organization
Organization Name:ABUNDANT WELLNESS
Other - Org Name:ABUNDANT WELLNESS MD LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:A
Authorized Official - Last Name:FARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-794-4652
Mailing Address - Street 1:8787 N OWASSO EXPY
Mailing Address - Street 2:SUITE J
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-4444
Mailing Address - Country:US
Mailing Address - Phone:918-516-2296
Mailing Address - Fax:918-516-2965
Practice Address - Street 1:8787 N OWASSO EXPY
Practice Address - Street 2:SUITE J
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4444
Practice Address - Country:US
Practice Address - Phone:918-516-2296
Practice Address - Fax:918-516-2965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-14
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty