Basic Information
| Provider Information | |||||||||
| NPI: | 1124694542 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMANCHE COUNTY HOSPITAL AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | LCHC MEDICINE PARK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3401 W GORE BLVD | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735056300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805855443 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 19055 STATE HIGHWAY 49 | ||||||||
| Address2: | |||||||||
| City: | MEDICINE PARK | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805855503 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2021 | ||||||||
| LastUpdateDate: | 12/21/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | BRENT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5805855522 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.