Provider Demographics
NPI:1578080883
Name:ADVANCED WELLNESS CLINIC, INC
Entity Type:Organization
Organization Name:ADVANCED WELLNESS CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:STUBBS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-224-5900
Mailing Address - Street 1:601 S MISSION ST
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-4657
Mailing Address - Country:US
Mailing Address - Phone:918-224-5900
Mailing Address - Fax:918-224-6642
Practice Address - Street 1:601 S MISSION ST
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-4657
Practice Address - Country:US
Practice Address - Phone:918-224-5900
Practice Address - Fax:918-224-6642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty