Healthcare Provider Details

I. General information

NPI: 1164590790
Provider Name (Legal Business Name): CIMARRON VALLEY THERAPEUTIC SERVICE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 9TH ST
WOODWARD OK
73801-3131
US

IV. Provider business mailing address

PO BOX 1041
WOODWARD OK
73802-1041
US

V. Phone/Fax

Practice location:
  • Phone: 580-254-2886
  • Fax: 580-254-3548
Mailing address:
  • Phone: 580-254-2886
  • Fax: 580-254-3548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberK8600113
License Number StateOK

VIII. Authorized Official

Name: STEVE W. GATES
Title or Position: PROGRAM DIRECTOR
Credential: M.B.S., LBP
Phone: 580-254-2886