Basic Information
| Provider Information | |||||||||
| NPI: | 1992292999 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMMEDIATE CARE OF OKLAHOMA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 720790 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730704614 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 10551 SE 59TH ST | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731504302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056006869 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2018 | ||||||||
| LastUpdateDate: | 04/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | PENWELL | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COM | ||||||||
| AuthorizedOfficialTelephone: | 4056006869 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.