1861789331 NPI number — LAWTON PSYCHIATRY SERVICES, LLC

Table of content: (NPI 1861789331)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861789331 NPI number — LAWTON PSYCHIATRY SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAWTON PSYCHIATRY SERVICES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861789331
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
605 W GORE BLVD STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAWTON
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73501-3732
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-357-7332
Provider Business Mailing Address Fax Number:
580-357-7455

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
605 W GORE BLVD STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAWTON
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73501-3732
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-357-7332
Provider Business Practice Location Address Fax Number:
580-357-7455
Provider Enumeration Date:
07/06/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BLACKBURN
Authorized Official First Name:
TAMMIE
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL BILLING
Authorized Official Telephone Number:
580-357-3034

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200331430A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100205610B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".