Basic Information
| Provider Information | |||||||||
| NPI: | 1376181479 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERAKI WELLNESS GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 54695 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731541695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056517607 | ||||||||
| FaxNumber: | 4059423873 | ||||||||
| Practice Location | |||||||||
| Address1: | 1211 N SHARTEL AVE STE 802 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731032425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056517607 | ||||||||
| FaxNumber: | 4059423873 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2019 | ||||||||
| LastUpdateDate: | 12/19/2019 | ||||||||
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| AuthorizedOfficialLastName: | TONO | ||||||||
| AuthorizedOfficialFirstName: | LUZ | ||||||||
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| AuthorizedOfficialTitleorPosition: | GENERAL PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 4056517607 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 12/19/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.