Provider Demographics
NPI:1619304847
Name:PBA WELLNESS,LLC
Entity Type:Organization
Organization Name:PBA WELLNESS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:RD/LD
Authorized Official - Phone:918-551-7901
Mailing Address - Street 1:4775 E 91ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-2801
Mailing Address - Country:US
Mailing Address - Phone:918-496-2000
Mailing Address - Fax:918-496-2338
Practice Address - Street 1:4775 E 91ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-2801
Practice Address - Country:US
Practice Address - Phone:918-496-2000
Practice Address - Fax:918-496-2338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1678133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty