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General NPI Number Information
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NPI Number | 1811709363
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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 | 01/22/2025
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Last Update Date | 01/22/2025
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Provider Practice Location Address
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Address Line | 805 W COVELL RD STE 200
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City | EDMOND
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State | OK
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Zip | 73003-2177
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Country | US
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Telephone | 405-216-5373
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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
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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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