Provider Demographics
NPI:1437738804
Name:DESTINY URGENT AND PRIMARY CARE CLINIC. LLC
Entity Type:Organization
Organization Name:DESTINY URGENT AND PRIMARY CARE CLINIC. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:KAARA
Authorized Official - Last Name:MAINA
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:417-317-3388
Mailing Address - Street 1:1000 W ELMIRA ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-0872
Mailing Address - Country:US
Mailing Address - Phone:417-317-3388
Mailing Address - Fax:
Practice Address - Street 1:1818 N HIGHWAY 66 STE B
Practice Address - Street 2:
Practice Address - City:CATOOSA
Practice Address - State:OK
Practice Address - Zip Code:74015-3052
Practice Address - Country:US
Practice Address - Phone:417-317-3388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-05
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1740751445OtherNPI#