Provider Demographics
NPI:1508503152
Name:RECLAIM WELLNESS LLC
Entity Type:Organization
Organization Name:RECLAIM WELLNESS LLC
Other - Org Name:RECLAIM WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACYE
Authorized Official - Middle Name:
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:405-819-5884
Mailing Address - Street 1:10932 NW EXPRESSWAY STE C
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-8764
Mailing Address - Country:US
Mailing Address - Phone:405-570-1010
Mailing Address - Fax:949-660-5841
Practice Address - Street 1:10932 NW EXPRESSWAY STE C
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-8764
Practice Address - Country:US
Practice Address - Phone:405-570-1010
Practice Address - Fax:949-660-5841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-16
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200657160Medicaid