Healthcare Provider Details

I. General information

NPI: 1891293759
Provider Name (Legal Business Name): PORT LAWRENCE BEHAVIORAL HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2018
Last Update Date: 01/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 NE 10TH ST
MIDWEST CITY OK
73110-3600
US

IV. Provider business mailing address

8617 HONEY LOCUST DR
SPENCER OK
73084-2115
US

V. Phone/Fax

Practice location:
  • Phone: 405-326-7721
  • Fax:
Mailing address:
  • Phone: 405-326-7721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. FRANK C. CALVIN
Title or Position: PRESIDENT
Credential: LADC/MH
Phone: 405-326-7721