Provider Demographics
NPI:1811187800
Name:FIRST CHOICE WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:FIRST CHOICE WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADDIE
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:GRATZ
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:580-371-0500
Mailing Address - Street 1:PO BOX 849
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-0849
Mailing Address - Country:US
Mailing Address - Phone:580-564-0500
Mailing Address - Fax:580-564-0250
Practice Address - Street 1:9 N MAIN
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:OK
Practice Address - Zip Code:73439-7343
Practice Address - Country:US
Practice Address - Phone:158-056-4050
Practice Address - Fax:580-564-0500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7588207Q00000X
OKR0067529364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200117140AMedicaid
OK200117140AMedicaid