Basic Information
| Provider Information | |||||||||
| NPI: | 1679231229 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMMEDIATE CARE OF OKLAHOMA - SE OKC LAB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5701 SE 74TH STREET | ||||||||
| Address2: | SUITE E | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731351110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056006869 | ||||||||
| FaxNumber: | 4056006978 | ||||||||
| Practice Location | |||||||||
| Address1: | 5700 SE 74TH STREET | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731351087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054001096 | ||||||||
| FaxNumber: | 4056006978 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2021 | ||||||||
| LastUpdateDate: | 12/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | PENWELL | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/COM | ||||||||
| AuthorizedOfficialTelephone: | 4056006869 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | 12/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.