Provider Demographics
NPI:1770666752
Name:TOTAL HEALTH & WELLNESS CENTER INC
Entity type:Organization
Organization Name:TOTAL HEALTH & WELLNESS CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:COTTINGAME
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:580-920-2555
Mailing Address - Street 1:1259 N WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-2119
Mailing Address - Country:US
Mailing Address - Phone:580-920-2555
Mailing Address - Fax:580-920-2666
Practice Address - Street 1:1259 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2119
Practice Address - Country:US
Practice Address - Phone:580-920-2555
Practice Address - Fax:580-920-2666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKDC3543111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK467277639001OtherBLUE CROSS BLUE SHIELD
OK790814OtherAETNA
OK200039580AMedicaid
OK200039580AMedicaid
OK200039580AMedicaid
OK=========OtherTAX IDENTIFICATION NUMBER