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General NPI Number Information
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NPI Number | 1417754334
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Entity Type | Organization
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Legal Business Name | ICO PRIMARY CARE LLC
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Dates
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Enumeration Date | 02/27/2025
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Last Update Date | 02/27/2025
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Provider Practice Location Address
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Address Line | 800 24TH AVE NW
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City | NORMAN
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State | OK
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Zip | 73069-6314
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Country | US
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Telephone | 405-321-7100
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Fax |
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Provider Business Mailing Address
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Address Line | 5701 SE 74TH ST STE E
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City | OKLAHOMA CITY
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State | OK
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Zip | 73135-1110
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Country | US
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Telephone | 405-600-6869
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Fax |
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Authorized Official
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Title or Position | PRESIDENT, CMO
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Name | KEVIN M PENWELL
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Credential | DO
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Telephone | 405-600-6869
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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