Provider Demographics
NPI:1417754334
Name:ICO PRIMARY CARE LLC
Entity type:Organization
Organization Name:ICO PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CMO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:M
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 1:800 24TH AVE NW
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6314
Practice Address - Country:US
Practice Address - Phone:405-321-7100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-27
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK201240380Medicaid