Basic Information
| Provider Information | |||||||||
| NPI: | 1245316447 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWESTERN MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5602 SW LEE BLVD | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735059635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805314700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5602 SW LEE BLVD | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735059635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805314700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 09/30/2010 | ||||||||
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| AuthorizedOfficialLastName: | COFFEY | ||||||||
| AuthorizedOfficialFirstName: | SHELTON | ||||||||
| AuthorizedOfficialMiddleName: | RAY | ||||||||
| AuthorizedOfficialTitleorPosition: | VP REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 6157643009 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHWESTERN MEDICAL CENTER, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 323P00000X | 2231 | OK | Y | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
ID Information
| ID | Type | State | Issuer | Description | 100697950F | 05 | OK | MEDICAID |