Provider Demographics
NPI:1871843920
Name:WELLNESS CENTER OF SOUTHERN OKLAHOMA, INC
Entity Type:Organization
Organization Name:WELLNESS CENTER OF SOUTHERN OKLAHOMA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:BAKER
Authorized Official - Last Name:FORE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:580-223-3737
Mailing Address - Street 1:1001 15TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1803
Mailing Address - Country:US
Mailing Address - Phone:580-223-3737
Mailing Address - Fax:580-223-4801
Practice Address - Street 1:1001 15TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1803
Practice Address - Country:US
Practice Address - Phone:580-223-3737
Practice Address - Fax:580-223-4801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-17
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty