Provider Demographics
NPI:1073154431
Name:IMPERIAL CONCIERGE CARE
Entity Type:Organization
Organization Name:IMPERIAL CONCIERGE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LARTAVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-619-8577
Mailing Address - Street 1:6805 LANCER LN
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-6033
Mailing Address - Country:US
Mailing Address - Phone:405-619-8577
Mailing Address - Fax:
Practice Address - Street 1:6805 LANCER LN
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73132-6033
Practice Address - Country:US
Practice Address - Phone:405-619-8577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty