=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730132697
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHCARE MANAGEMENT GROUP OF LAWTON INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4202 SW LEE BLVD BLDG B, STE 204D
-----------------------------------------------------
City | LAWTON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73505-8300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-248-8481
-----------------------------------------------------
Fax | 580-248-8996
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4202 SW LEE BLVD BLDG B, STE 204D
-----------------------------------------------------
City | LAWTON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73505-8300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-248-8481
-----------------------------------------------------
Fax | 580-248-8996
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. SAM GHOSN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 580-248-8481
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------