Provider Demographics
NPI:1265813307
Name:WELLSPRING FAMILY CLINIC LLC
Entity type:Organization
Organization Name:WELLSPRING FAMILY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:
Authorized Official - Last Name:SAGER
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:918-461-0422
Mailing Address - Street 1:4623 W KENOSHA ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-8975
Mailing Address - Country:US
Mailing Address - Phone:918-461-0422
Mailing Address - Fax:918-461-0428
Practice Address - Street 1:104 S OAK ST
Practice Address - Street 2:STE. B
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-4624
Practice Address - Country:US
Practice Address - Phone:918-775-0075
Practice Address - Fax:918-775-0063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty