Provider Demographics
NPI:1851744312
Name:PRIMARY CARE OF ADA, LLC
Entity Type:Organization
Organization Name:PRIMARY CARE OF ADA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:RANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:IVY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-272-0485
Mailing Address - Street 1:1705 CRADDUCK RD STE B
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-9491
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1705 CRADDUCK RD
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-9491
Practice Address - Country:US
Practice Address - Phone:580-279-6313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-20
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty