Provider Demographics
NPI:1700120458
Name:HEALTHY LIFE PLLC
Entity Type:Organization
Organization Name:HEALTHY LIFE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-344-9368
Mailing Address - Street 1:800 W BOISE CIR
Mailing Address - Street 2:SUITE 290
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-4906
Mailing Address - Country:US
Mailing Address - Phone:918-344-9368
Mailing Address - Fax:
Practice Address - Street 1:800 W BOISE CIR
Practice Address - Street 2:SUITE 290
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-4906
Practice Address - Country:US
Practice Address - Phone:918-344-9368
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-19
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21264207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty