Healthcare Provider Details

I. General information

NPI: 1710120258
Provider Name (Legal Business Name): COMANCHE COUNTY HOSPITAL AUTHORITY SOUTHWEST RADIOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2009
Last Update Date: 06/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11447 DUTCH IRIS DR
RIVERVIEW FL
33578-3728
US

IV. Provider business mailing address

PO BOX 2309
LAWTON OK
73502-2309
US

V. Phone/Fax

Practice location:
  • Phone: 580-585-2717
  • Fax:
Mailing address:
  • Phone: 800-945-2455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number115285
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID BLACKMON
Title or Position: CFO
Credential:
Phone: 580-355-8699