Healthcare Provider Details

I. General information

NPI: 1790089829
Provider Name (Legal Business Name): SOUTHERN OKLAHOMA TREATMENT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2011
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5862 US HWY 70
MEAD OK
73449
US

IV. Provider business mailing address

PO BOX 48
MEAD OK
73449-0048
US

V. Phone/Fax

Practice location:
  • Phone: 580-745-9610
  • Fax:
Mailing address:
  • Phone: 580-745-9610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number20938
License Number StateOK

VIII. Authorized Official

Name: MR. MILTON EVANS
Title or Position: CEO
Credential:
Phone: 5805807459610