Provider Demographics
NPI:1831757954
Name:ICARE CENTER CHANDLER LLC
Entity type:Organization
Organization Name:ICARE CENTER CHANDLER 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:405-682-8383
Mailing Address - Street 1:PO BOX 610
Mailing Address - Street 2:
Mailing Address - City:CANUTE
Mailing Address - State:OK
Mailing Address - Zip Code:73626-0610
Mailing Address - Country:US
Mailing Address - Phone:405-682-8383
Mailing Address - Fax:405-265-5230
Practice Address - Street 1:200 PRAIRE LANE
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:OK
Practice Address - Zip Code:74834
Practice Address - Country:US
Practice Address - Phone:405-682-8383
Practice Address - Fax:405-265-5230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-04
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty