Basic Information
| Provider Information | |||||||||
| NPI: | 1609315308 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMANCHE COUNTY HEALTHCARE CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MMG EAR, NOSE AND THROAT CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 785 | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735020785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803579984 | ||||||||
| FaxNumber: | 5803573277 | ||||||||
| Practice Location | |||||||||
| Address1: | 3201 W GORE BLVD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735056378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802506555 | ||||||||
| FaxNumber: | 5803545942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2017 | ||||||||
| LastUpdateDate: | 06/29/2020 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | BRENT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5803558620 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.