Provider Demographics
NPI:1609041136
Name:CANCER CENTERS OF SOUTHWEST OKLAHOMA, LLC
Entity Type:Organization
Organization Name:CANCER CENTERS OF SOUTHWEST OKLAHOMA, LLC
Other - Org Name:SOUTHWEST OKLAHOMA CANCER CENTER, L.L.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHEIF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOOTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-536-2121
Mailing Address - Street 1:104 NW 31ST ST
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-6100
Mailing Address - Country:US
Mailing Address - Phone:580-536-2121
Mailing Address - Fax:580-536-2150
Practice Address - Street 1:1200 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-5702
Practice Address - Country:US
Practice Address - Phone:580-480-4400
Practice Address - Fax:580-480-4416
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CANCER CENTERS OF SOUTHWEST OKLAHOMA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-25
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK207RH0003X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200280260CMedicaid
OK200280260EMedicaid
OK6502330002OtherNSC
OKOKB5911Medicare PIN
OK200280260CMedicaid