Provider Demographics
NPI:1750482741
Name:PERRY WELLNESS CENTER PLLC
Entity Type:Organization
Organization Name:PERRY WELLNESS CENTER PLLC
Other - Org Name:PERRY WELLNES CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNERPHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JONTHAN
Authorized Official - Middle Name:RADKOFF
Authorized Official - Last Name:EK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-336-3735
Mailing Address - Street 1:501 N 14TH ST
Mailing Address - Street 2:ATTN: J. EK
Mailing Address - City:PERRY
Mailing Address - State:OK
Mailing Address - Zip Code:73077-5021
Mailing Address - Country:US
Mailing Address - Phone:580-336-3735
Mailing Address - Fax:580-336-3738
Practice Address - Street 1:501 N 14TH ST
Practice Address - Street 2:ATTN: J. EK
Practice Address - City:PERRY
Practice Address - State:OK
Practice Address - Zip Code:73077-5021
Practice Address - Country:US
Practice Address - Phone:580-336-3735
Practice Address - Fax:580-336-3738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23862207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK32819OtherBNDD