Provider Demographics
NPI:1891293759
Name:PORT LAWRENCE BEHAVIORAL HEALTH SERVICES LLC
Entity Type:Organization
Organization Name:PORT LAWRENCE BEHAVIORAL HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:C
Authorized Official - Last Name:CALVIN
Authorized Official - Suffix:
Authorized Official - Credentials:LADC/MH
Authorized Official - Phone:405-326-7721
Mailing Address - Street 1:8617 HONEY LOCUST DR
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:OK
Mailing Address - Zip Code:73084-2115
Mailing Address - Country:US
Mailing Address - Phone:405-326-7721
Mailing Address - Fax:
Practice Address - Street 1:7901 NE 10TH ST
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-3600
Practice Address - Country:US
Practice Address - Phone:405-326-7721
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251S00000X
324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility