1679694632 NPI number — MARIE DETTY YOUTH & FAMILY SERVICES CENTER, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679694632 NPI number — MARIE DETTY YOUTH & FAMILY SERVICES CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARIE DETTY YOUTH & FAMILY SERVICES CENTER, INC.
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:
1679694632
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 408
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:
73502-0408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-250-1123
Provider Business Mailing Address Fax Number:
580-248-0171

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2501 SW E AVE
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:
73505-7320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-248-6450
Provider Business Practice Location Address Fax Number:
580-248-6486
Provider Enumeration Date:
04/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
OWENS
Authorized Official First Name:
DIANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
508-250-1123

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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