Provider Demographics
NPI:1730428939
Name:AFFORDABLE WEIGHT LOSS AND PAIN MANAGEMENT CLINIC PLLC
Entity type:Organization
Organization Name:AFFORDABLE WEIGHT LOSS AND PAIN MANAGEMENT CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JARRETT
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-224-2669
Mailing Address - Street 1:810 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-4527
Mailing Address - Country:US
Mailing Address - Phone:580-224-2669
Mailing Address - Fax:580-319-5294
Practice Address - Street 1:810 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-4527
Practice Address - Country:US
Practice Address - Phone:580-224-2669
Practice Address - Fax:580-319-5294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-07
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13611208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty