1790418283 NPI number — DIVERSITY HEALTH AND WELLNESS

Table of content: (NPI 1790418283)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790418283 NPI number — DIVERSITY HEALTH AND WELLNESS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIVERSITY HEALTH AND WELLNESS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CHRONIC CARDZ
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790418283
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
310 NE 28TH ST STE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73105-2837
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-902-1142
Provider Business Mailing Address Fax Number:
405-444-3014

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 NE 28TH ST STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73105-2837
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
844-902-1142
Provider Business Practice Location Address Fax Number:
405-444-3014
Provider Enumeration Date:
07/02/2022

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ROBINSON
Authorized Official First Name:
SHANTELL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
405-276-2029

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 171400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RA0201X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364SH1100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1790418283 , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 717708 , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: F0610518 , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1558675074 , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 363L00000X , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: N083704850 . This is a "TELE HEALTH SERVICES" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".