Provider Demographics
NPI:1881190833
Name:ICARE CENTER LLC
Entity Type:Organization
Organization Name:ICARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:SENTHIL
Authorized Official - Middle Name:K
Authorized Official - Last Name:RAJU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-391-5526
Mailing Address - Street 1:21001 SE 29TH ST
Mailing Address - Street 2:
Mailing Address - City:HARRAH
Mailing Address - State:OK
Mailing Address - Zip Code:73045-6591
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21001 SE 29TH ST UNIT 1
Practice Address - Street 2:
Practice Address - City:HARRAH
Practice Address - State:OK
Practice Address - Zip Code:73045-6577
Practice Address - Country:US
Practice Address - Phone:405-391-5526
Practice Address - Fax:405-391-5529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-30
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========OtherTIN