Healthcare Provider Details

I. General information

NPI: 1881614733
Provider Name (Legal Business Name): COMANCHE COUNTY HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 11/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 W GORE BLVD SUITE 202
LAWTON OK
73505-6378
US

IV. Provider business mailing address

PO BOX 785
LAWTON OK
73502
US

V. Phone/Fax

Practice location:
  • Phone: 580-355-6731
  • Fax: 580-250-5806
Mailing address:
  • Phone: 580-357-9984
  • Fax: 580-357-3277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number18140
License Number StateOK

VIII. Authorized Official

Name: DAVID BLACKMON
Title or Position: CFO
Credential:
Phone: 580-355-8620