Provider Demographics
NPI:1922671551
Name:ICARE PRIMARY & WELLNESS CLINIC LLC
Entity Type:Organization
Organization Name:ICARE PRIMARY & WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KAMI
Authorized Official - Middle Name:
Authorized Official - Last Name:SCRUGGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-658-8904
Mailing Address - Street 1:1145 W I 240 SERVICE RD # BDLF10
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-2171
Mailing Address - Country:US
Mailing Address - Phone:405-658-8904
Mailing Address - Fax:
Practice Address - Street 1:4823 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-3835
Practice Address - Country:US
Practice Address - Phone:405-673-4045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty