Provider Demographics
NPI:1710120258
Name:COMANCHE COUNTY HOSPITAL AUTHORITY SOUTHWEST RADIOLOGY
Entity Type:Organization
Organization Name:COMANCHE COUNTY HOSPITAL AUTHORITY SOUTHWEST RADIOLOGY
Other - Org Name:
Other - Org Type:
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:580-355-8699
Mailing Address - Street 1:PO BOX 2309
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73502-2309
Mailing Address - Country:US
Mailing Address - Phone:800-945-2455
Mailing Address - Fax:
Practice Address - Street 1:11447 DUTCH IRIS DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-3728
Practice Address - Country:US
Practice Address - Phone:580-585-2717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-14
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2085R0202X
FL1152852085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty