NPIMap

Organization Active NPI

Grand Lake Medical and Wellness Corp

Doing business as Serena Wilson

  • Pain Clinic/Center
  • Sallisaw, OK
National Provider Identifier
1336706118
Registry record updated May 28, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pain Clinic/CenterTaxonomy code 261QP3300X
Legal business name
GRAND LAKE MEDICAL AND WELLNESS CORP
Doing business as
Serena Wilson
Practice address
101 W Quesenbury Ave
Sallisaw, OK 74955-3613
Phone
(918) 235-6877
NPI assigned
May 28, 2019
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 28, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Serena B Wilson, APRNNPI 1881946259
Title
Owner
Phone
(918) 961-1658

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Clinic/Center 261QP2300X
Pain Clinic/Center 261QP3300X Primary

Addresses

Primary practice location

101 W Quesenbury Ave
Sallisaw, OK 74955-3613

Mailing address

58700 E 190 Rd
Fairland, OK 74343-2500

Other practice location 1

302 N Greenwood Ave
Fort Smith, AR 72901-3454
Phone (479) 434-3600

Other names 1

  • Serena Wilson Doing business as

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1559001600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1559001600000",
    "number": "1336706118",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "58700 E 190 RD",
            "city": "FAIRLAND",
            "state": "OK",
            "postal_code": "743432500"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "101 W QUESENBURY AVE",
            "city": "SALLISAW",
            "state": "OK",
            "postal_code": "749553613",
            "telephone_number": "918-235-6877"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "302 N Greenwood Ave",
            "address_purpose": "LOCATION",
            "city": "Fort Smith",
            "state": "AR",
            "postal_code": "729013454",
            "country_code": "US",
            "telephone_number": "479-434-3600",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "GRAND LAKE MEDICAL AND WELLNESS CORP",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-05-28",
        "last_updated": "2019-05-28",
        "status": "A",
        "authorized_official_last_name": "WILSON",
        "authorized_official_first_name": "SERENA",
        "authorized_official_middle_name": "B",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "918-961-1658",
        "authorized_official_credential": "APRN"
    },
    "taxonomies": [
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QP3300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Pain",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Serena Wilson",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Sallisaw, OK

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 28, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.