Basic Information
| Provider Information | |||||||||
| NPI: | 1720314875 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLNESS AND LONGEVITY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7530 NW 23RD ST | ||||||||
| Address2: | |||||||||
| City: | BETHANY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730084921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057878556 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7530 NW 23RD ST | ||||||||
| Address2: | |||||||||
| City: | BETHANY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730084921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057878556 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2009 | ||||||||
| LastUpdateDate: | 10/26/2009 | ||||||||
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| AuthorizedOfficialLastName: | ROTHWELL | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 4057878556 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133NN1002X | 10533 | OK | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education | 208D00000X | 10533 | OK | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 207Q00000X | 10533 | OK | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.