1295383289 NPI number — KETO WELLNESS AND HORMONE CLINIC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295383289 NPI number — KETO WELLNESS AND HORMONE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KETO WELLNESS AND HORMONE CLINIC
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:
Provider Other Organization Name Type Code:
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:
1295383289
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 N PORTER AVE STE 212
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORMAN
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73071-6485
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-217-2922
Provider Business Mailing Address Fax Number:
405-217-2940

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 N PORTER AVE STE 212
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORMAN
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73071-6485
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-217-2922
Provider Business Practice Location Address Fax Number:
405-217-2940
Provider Enumeration Date:
09/03/2019

Additional Information

Authorized Official

Authorized Official Last Name:
RESNEDER
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
RAY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
405-217-2922

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1316989205 , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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