Healthcare Provider Details

I. General information

NPI: 1215952023
Provider Name (Legal Business Name): THE BREAST CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5604 SW LEE BLVD SUITE 150
LAWTON OK
73505-9681
US

IV. Provider business mailing address

5604 SW LEE BLVD SUITE 150
LAWTON OK
73505-9681
US

V. Phone/Fax

Practice location:
  • Phone: 580-536-9729
  • Fax: 580-536-2584
Mailing address:
  • Phone: 580-536-9729
  • Fax: 580-536-2584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number141952
License Number StateOK

VIII. Authorized Official

Name: MRS. MONIQUE C PRESTON
Title or Position: EXEC. CORP. DIRECTOR
Credential:
Phone: 580-536-9729