Provider Demographics
NPI:1790418283
Name:DIVERSITY HEALTH AND WELLNESS
Entity Type:Organization
Organization Name:DIVERSITY HEALTH AND WELLNESS
Other - Org Name:CHRONIC CARDZ
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANTELL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:405-276-2029
Mailing Address - Street 1:310 NE 28TH ST STE 203
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105-2837
Mailing Address - Country:US
Mailing Address - Phone:844-902-1142
Mailing Address - Fax:405-444-3014
Practice Address - Street 1:310 NE 28TH ST STE 203
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-2837
Practice Address - Country:US
Practice Address - Phone:844-902-1142
Practice Address - Fax:405-444-3014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-02
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No171400000XOther Service ProvidersHealth & Wellness CoachGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & ImmunologyGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No364SH1100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistHolisticGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1790418283Medicaid
OK717708Medicaid
OKF0610518Medicaid
OK1558675074Medicaid
OK363L00000XMedicaid
OKN083704850OtherTELE HEALTH SERVICES