Provider Demographics
NPI:1336706118
Name:GRAND LAKE MEDICAL AND WELLNESS CORP
Entity Type:Organization
Organization Name:GRAND LAKE MEDICAL AND WELLNESS CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SERENA
Authorized Official - Middle Name:B
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:918-961-1658
Mailing Address - Street 1:58700 E 190 RD
Mailing Address - Street 2:
Mailing Address - City:FAIRLAND
Mailing Address - State:OK
Mailing Address - Zip Code:74343-2500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 W QUESENBURY AVE
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-3613
Practice Address - Country:US
Practice Address - Phone:918-235-6877
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care