Provider Demographics
NPI:1750429148
Name:AGAPE' WELLNESS CENTER & WOUND CARE, LLC
Entity type:Organization
Organization Name:AGAPE' WELLNESS CENTER & WOUND CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:HUBERT
Authorized Official - Middle Name:H
Authorized Official - Last Name:WATTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-869-3466
Mailing Address - Street 1:P. O. BOX 9281 RTE # 2
Mailing Address - Street 2:
Mailing Address - City:KINGSHILL
Mailing Address - State:VI
Mailing Address - Zip Code:00851
Mailing Address - Country:US
Mailing Address - Phone:340-778-0688
Mailing Address - Fax:
Practice Address - Street 1:PLOT 6 CLIFTON HILL
Practice Address - Street 2:
Practice Address - City:KINGSHILL
Practice Address - State:VI
Practice Address - Zip Code:00851
Practice Address - Country:US
Practice Address - Phone:340-778-0688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23898207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200046880BMedicaid
OK700522158OtherMEDICARE B
OK200046880AMedicaid
OK200046880BMedicaid