Provider Demographics
NPI:1629842000
Name:WESTERN OKLAHOMA WELLNESS LLC
Entity Type:Organization
Organization Name:WESTERN OKLAHOMA WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARITY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, AGNP-C
Authorized Official - Phone:505-610-4001
Mailing Address - Street 1:1406 WALTERS WAY
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-2422
Mailing Address - Country:US
Mailing Address - Phone:505-610-4001
Mailing Address - Fax:
Practice Address - Street 1:1710 W 3RD ST STE 101
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-5160
Practice Address - Country:US
Practice Address - Phone:580-225-8600
Practice Address - Fax:855-583-1074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care