Basic Information
| Provider Information | |||||||||
| NPI: | 1588832869 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMANCHE COUNTY HOSPITAL AUTHORITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAWTON COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2309 | ||||||||
| Address2: | SECTION 2 | ||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735022309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803555242 | ||||||||
| FaxNumber: | 5803555245 | ||||||||
| Practice Location | |||||||||
| Address1: | 5404 SW LEE BLVD | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803555242 | ||||||||
| FaxNumber: | 5803555245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2008 | ||||||||
| LastUpdateDate: | 09/18/2014 | ||||||||
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| AuthorizedOfficialLastName: | MCAVOY | ||||||||
| AuthorizedOfficialFirstName: | SEAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5802804413 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 100700750Z | 05 | OK | MEDICAID |