Provider Demographics
NPI:1326276189
Name:BREASTFEEDING GUIDANCE CENTER OF SOUTHWEST OKLAHOMA
Entity Type:Organization
Organization Name:BREASTFEEDING GUIDANCE CENTER OF SOUTHWEST OKLAHOMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT FOR THE LLC
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:CAROLE
Authorized Official - Last Name:GILLILAND
Authorized Official - Suffix:
Authorized Official - Credentials:RN BSN IBCLC
Authorized Official - Phone:580-591-3817
Mailing Address - Street 1:8237 NW STONEBRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-4127
Mailing Address - Country:US
Mailing Address - Phone:580-536-3743
Mailing Address - Fax:580-536-3743
Practice Address - Street 1:711 SW D AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-4561
Practice Address - Country:US
Practice Address - Phone:580-591-3817
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0027885261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100749570SMedicaid