Provider Demographics
NPI:1659647501
Name:COMANCHE COUNTY HEALTHCARE CORP
Entity Type:Organization
Organization Name:COMANCHE COUNTY HEALTHCARE CORP
Other - Org Name:MEMORIAL MEDICAL GROUP FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-355-8620
Mailing Address - Street 1:PO BOX 785
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73502-0785
Mailing Address - Country:US
Mailing Address - Phone:580-357-9984
Mailing Address - Fax:580-357-3277
Practice Address - Street 1:3201 W GORE BLVD
Practice Address - Street 2:STE 300
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-6378
Practice Address - Country:US
Practice Address - Phone:580-585-5549
Practice Address - Fax:580-354-5911
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMANCHE COUNTY HEALTHCARE CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-26
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty