MEDICARE: IMMEDIATE CARE OF OKLAHOMA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QU0200X	Urgent Care Clinic/Center		OK

General Provider Information

NPI Number	:	1699262576
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMMEDIATE CARE OF OKLAHOMA, LLC

Provider Business Mailing Address
First Line	:	PO BOX 720790
Second Line	:
City	:	NORMAN
State	:	OK
Zip	:	73070-4614
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4500 TINKER RD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73135-4614
Country	:	US
Telephone Number	:	405-600-6869
Fax Number	:

Authorized Official
Title or Position	:	COM
Name	:	KEVIN PENWELL
Credential	:	DO
Telephone Number	:	405-600-6869

Provider Enumeration Date	:	04/17/2018
Last Update Date	:	04/17/2018

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