1154753614 NPI number — IMMEDIATE CARE OF OKLAHOMA LLC

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 1154753614 NPI number — IMMEDIATE CARE OF OKLAHOMA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IMMEDIATE CARE OF OKLAHOMA LLC
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:
1154753614
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8001 S I 35 SERVICE RD
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73149-2906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-600-6869
Provider Business Mailing Address Fax Number:
405-600-6978

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
805 W COVELL RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
EDMOND
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73003-2176
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-216-5373
Provider Business Practice Location Address Fax Number:
405-216-5017
Provider Enumeration Date:
08/06/2013

Additional Information

Authorized Official

Authorized Official Last Name:
PENWELL
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
COM/MEDICAL DIRECTOR
Authorized Official Telephone Number:
405-600-6869

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X , with the licence number:  3873 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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