Healthcare Provider Details

I. General information

NPI: 1053530568
Provider Name (Legal Business Name): COMANCHE COUNTY HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 01/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 W GORE BLVD SUITE 105
LAWTON OK
73505
US

IV. Provider business mailing address

PO BOX 785
LAWTON OK
73502
US

V. Phone/Fax

Practice location:
  • Phone: 580-510-7077
  • Fax: 580-510-7057
Mailing address:
  • Phone: 580-357-9984
  • Fax: 580-357-3277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25416
License Number StateOK

VIII. Authorized Official

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