Provider Demographics
NPI:1568144996
Name:ICO PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:ICO PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PENWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:405-600-6869
Mailing Address - Street 1:5701 SE 74TH ST STE E
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73135-1110
Mailing Address - Country:US
Mailing Address - Phone:405-600-6869
Mailing Address - Fax:
Practice Address - Street 1:5700 SE 74TH ST STE 100B
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73135-1087
Practice Address - Country:US
Practice Address - Phone:405-455-5204
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-04
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care