Organization
GRAND LAKE MEDICAL AND WELLNESS CORP
Active
Other names
Serena Wilson
Organization subpart
No
Provider details
NPI number
Authorized official
SERENA B WILSON APRN (OWNER)
(918) 961-1658
Entity
Organization
Contact information
Practice address
101 W QUESENBURY AVE, SALLISAW, OK 74955-3613
(918) 235-6877
Mailing address
58700 E 190 RD, FAIRLAND, OK 74343-2500
Taxonomy
Speciality
Code
Description
License number
State
261QP2300X
Primary Care Clinic/Center
—
—
261QP3300X
Pain Clinic/Center
Primary
—
—
Other
Enumeration date
05/28/2019
Last updated
05/28/2019
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