Provider Demographics
NPI:1649563958
Name:OWASSO WELLNESS PLLC
Entity Type:Organization
Organization Name:OWASSO WELLNESS PLLC
Other - Org Name:NORTHSIDE FAMILY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-274-3888
Mailing Address - Street 1:13720 E 86TH ST N
Mailing Address - Street 2:SUITE 130
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-8704
Mailing Address - Country:US
Mailing Address - Phone:918-274-3888
Mailing Address - Fax:
Practice Address - Street 1:13720 E 86TH ST N
Practice Address - Street 2:SUITE 130
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-8704
Practice Address - Country:US
Practice Address - Phone:918-274-3888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-18
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3999111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty