Healthcare Provider Details

I. General information

NPI: 1700700416
Provider Name (Legal Business Name): VIP PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3816 W VAN BUREN ST
BROKEN ARROW OK
74011-1912
US

IV. Provider business mailing address

3816 W VAN BUREN ST
BROKEN ARROW OK
74011-1912
US

V. Phone/Fax

Practice location:
  • Phone: 918-704-1240
  • Fax:
Mailing address:
  • Phone: 918-704-1240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MADISON HIBBARD
Title or Position: CEO
Credential:
Phone: 918-704-1240