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General NPI Number Information
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NPI Number | 1679231229
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Entity Type | Organization
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Legal Business Name | IMMEDIATE CARE OF OKLAHOMA - SE OKC LAB
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Dates
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Enumeration Date | 12/01/2021
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Last Update Date | 12/01/2021
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Provider Practice Location Address
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Address Line | 5700 SE 74TH STREET SUITE 100
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City | OKLAHOMA CITY
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State | OK
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Zip | 73135-1087
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Country | US
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Telephone | 405-400-1096
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Fax | 405-600-6978
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Provider Business Mailing Address
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Address Line | 5701 SE 74TH STREET SUITE 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 | 405-600-6978
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Authorized Official
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Title or Position | PRESIDENT/COM
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Name | KEVIN PENWELL
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Credential | D.O.
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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 | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number |
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License Number State |
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