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General NPI Number Information
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NPI Number | 1437738804
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Entity Type | Organization
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Legal Business Name | DESTINY URGENT AND PRIMARY CARE CLINIC. LLC
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Dates
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Enumeration Date | 04/05/2021
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Last Update Date | 04/22/2021
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Provider Practice Location Address
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Address Line | 1818 N HIGHWAY 66 STE B
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City | CATOOSA
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State | OK
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Zip | 74015-3052
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Country | US
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Telephone | 417-317-3388
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Fax |
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Provider Business Mailing Address
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Address Line | 1000 W ELMIRA ST
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City | BROKEN ARROW
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State | OK
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Zip | 74012-0872
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Country | US
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Telephone | 417-317-3388
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Fax |
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | ERNEST KAARA MAINA
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Credential | FNP
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Telephone | 417-317-3388
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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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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Taxonomy #4
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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