Provider Demographics
NPI:1295583508
Name:LIBERTAD WELLNESS CENTER LLC
Entity type:Organization
Organization Name:LIBERTAD WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PRUDENCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:IJEOMA TANKEU
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:405-689-9303
Mailing Address - Street 1:2915 N CLASSEN BLVD STE 120-F509
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73106-5400
Mailing Address - Country:US
Mailing Address - Phone:405-689-9303
Mailing Address - Fax:405-229-5071
Practice Address - Street 1:2915 N CLASSEN BLVD STE 120-F509
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-5400
Practice Address - Country:US
Practice Address - Phone:405-689-9303
Practice Address - Fax:405-229-5071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-10
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No171400000XOther Service ProvidersHealth & Wellness CoachGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder