Healthcare Provider Details

I. General information

NPI: 1154753614
Provider Name (Legal Business Name): IMMEDIATE CARE OF OKLAHOMA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2013
Last Update Date: 08/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 W COVELL RD SUITE 200
EDMOND OK
73003-2176
US

IV. Provider business mailing address

8001 S I 35 SERVICE RD SUITE 106
OKLAHOMA CITY OK
73149-2906
US

V. Phone/Fax

Practice location:
  • Phone: 405-216-5373
  • Fax: 405-216-5017
Mailing address:
  • Phone: 405-600-6869
  • Fax: 405-600-6978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number3873
License Number StateOK

VIII. Authorized Official

Name: DR. KEVIN M PENWELL
Title or Position: COM/MEDICAL DIRECTOR
Credential: DO
Phone: 405-600-6869