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General NPI Number Information
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NPI Number | 1922518448
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Entity Type | Organization
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Legal Business Name | LAWTON DIALYSIS CENTER LLC
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Dates
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Enumeration Date | 10/11/2017
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Last Update Date | 01/12/2023
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Provider Practice Location Address
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Address Line | 5110 W GORE BLVD
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City | LAWTON
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State | OK
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Zip | 73505-5909
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Country | US
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Telephone | 580-248-3733
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Fax | 580-248-3993
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Provider Business Mailing Address
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Address Line | 5110 W GORE BLVD
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City | LAWTON
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State | OK
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Zip | 73505-5909
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Country | US
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Telephone | 580-248-3733
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Fax | 580-248-3993
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Authorized Official
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Title or Position | OWNER
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Name | BALI REDDY SODAM
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Credential |
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Telephone | 580-536-5273
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QE0700X
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Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
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License Number |
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License Number State |
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