Provider Demographics
NPI:1477009256
Name:AMATTCO LLC
Entity Type:Organization
Organization Name:AMATTCO LLC
Other - Org Name:NEW LEAF WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING PHYSICAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:RYKER
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:405-751-9800
Mailing Address - Street 1:3705 WEST MEMORIAL RD
Mailing Address - Street 2:SUITE 601
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1512
Mailing Address - Country:US
Mailing Address - Phone:405-751-9800
Mailing Address - Fax:405-751-9808
Practice Address - Street 1:3100 S ELM PL
Practice Address - Street 2:SUITE B
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-7950
Practice Address - Country:US
Practice Address - Phone:918-884-7800
Practice Address - Fax:918-731-4518
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMATTCO LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9365174400000X
OK73548174400000X
OK79139363L00000X
OKR0078723363L00000X
OK86262363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty