Healthcare Provider Details

I. General information

NPI: 1245254705
Provider Name (Legal Business Name): COMANCHE COUNTY HOSPITAL AUTHORITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 12/14/2020
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 W GORE BLVD SUITE 301
LAWTON OK
73505-6378
US

IV. Provider business mailing address

3401 W GORE BLVD
LAWTON OK
73505-6332
US

V. Phone/Fax

Practice location:
  • Phone: 580-248-8225
  • Fax: 580-248-8919
Mailing address:
  • Phone: 580-585-5443
  • Fax: 580-585-5553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11906
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: JULIE KILGORE
Title or Position: CREDENTIALING
Credential:
Phone: 580-585-5443