Basic Information
| Provider Information | |||||||||
| NPI: | 1750709903 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN OKLAHOMA TREATMENT SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 48 | ||||||||
| Address2: | |||||||||
| City: | MEAD | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734490048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5807459610 | ||||||||
| FaxNumber: | 5807459891 | ||||||||
| Practice Location | |||||||||
| Address1: | 1309 SW WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735017231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803557500 | ||||||||
| FaxNumber: | 5803557502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2014 | ||||||||
| LastUpdateDate: | 04/04/2014 | ||||||||
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| AuthorizedOfficialLastName: | MURPHY | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
| AuthorizedOfficialMiddleName: | RENE | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF ADMINSTRATIVE | ||||||||
| AuthorizedOfficialTelephone: | 5807459610 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 200049040 | 05 | OK | MEDICAID |