Provider Demographics
NPI:1902437346
Name:MED SPA AT ENID LIVE WELL
Entity Type:Organization
Organization Name:MED SPA AT ENID LIVE WELL
Other - Org Name:ENID LIVE WELL
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:VIKI
Authorized Official - Middle Name:SHARLAIN
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:580-233-4300
Mailing Address - Street 1:2111 N VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-2524
Mailing Address - Country:US
Mailing Address - Phone:580-233-4300
Mailing Address - Fax:580-350-6401
Practice Address - Street 1:2111 N VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-2524
Practice Address - Country:US
Practice Address - Phone:580-233-4300
Practice Address - Fax:580-350-6401
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VIKI WHITE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-02-03
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPainGroup - Multi-Specialty