Provider Demographics
NPI:1720314875
Name:WELLNESS AND LONGEVITY LLC
Entity Type:Organization
Organization Name:WELLNESS AND LONGEVITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROTHWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-787-8556
Mailing Address - Street 1:7530 NW 23RD ST
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008-4921
Mailing Address - Country:US
Mailing Address - Phone:405-787-8556
Mailing Address - Fax:
Practice Address - Street 1:7530 NW 23RD ST
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-4921
Practice Address - Country:US
Practice Address - Phone:405-787-8556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-26
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10533133NN1002X, 207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty