Provider Demographics
NPI:1457013328
Name:CHOCTAW HEALTH & WELLNESS CLINIC, LLC
Entity Type:Organization
Organization Name:CHOCTAW HEALTH & WELLNESS CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-281-1027
Mailing Address - Street 1:14890 SE 29TH ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020
Mailing Address - Country:US
Mailing Address - Phone:405-281-1027
Mailing Address - Fax:405-281-1006
Practice Address - Street 1:14890 SE 29TH ST
Practice Address - Street 2:SUITE 106
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020
Practice Address - Country:US
Practice Address - Phone:405-281-1027
Practice Address - Fax:405-281-1006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-08
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty