Basic Information
| Provider Information | |||||||||
| NPI: | 1578932299 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IMMEDIATE CARE OF OKLAHOMA L.L.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5700 SE 74TH | ||||||||
| Address2: | |||||||||
| City: | OKC | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731351106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056006869 | ||||||||
| FaxNumber: | 4056006978 | ||||||||
| Practice Location | |||||||||
| Address1: | 5700 SE 74TH ST | ||||||||
| Address2: | |||||||||
| City: | OKC | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731351106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056006869 | ||||||||
| FaxNumber: | 4056006978 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2015 | ||||||||
| LastUpdateDate: | 10/06/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PENWELL | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COM, PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4056006869 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | 4106 | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.