Basic Information
| Provider Information | |||||||||
| NPI: | 1649290644 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMANCHE COUNTY HEALTHCARE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEMORIAL MEDICAL GROUP PHYSICAL MEDICINE & REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 785 | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803579984 | ||||||||
| FaxNumber: | 5803573277 | ||||||||
| Practice Location | |||||||||
| Address1: | 3201 W GORE BLVD | ||||||||
| Address2: | STE 104 | ||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735056378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802506659 | ||||||||
| FaxNumber: | 5802505249 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 05/08/2015 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | BRENT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5803558620 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 4083 | OK | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.