Provider Demographics
NPI:1982861134
Name:SOUTH WESTERN OKLAHOMA DEVELOPMENT AUTHORITY
Entity Type:Organization
Organization Name:SOUTH WESTERN OKLAHOMA DEVELOPMENT AUTHORITY
Other - Org Name:SWODA
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GORSHING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-562-4882
Mailing Address - Street 1:PO BOX 569
Mailing Address - Street 2:
Mailing Address - City:BURNS FLAT
Mailing Address - State:OK
Mailing Address - Zip Code:73624-0569
Mailing Address - Country:US
Mailing Address - Phone:580-562-4882
Mailing Address - Fax:580-562-4880
Practice Address - Street 1:420 SOONER DRIVE
Practice Address - Street 2:
Practice Address - City:BURNS FLAT
Practice Address - State:OK
Practice Address - Zip Code:73624-0569
Practice Address - Country:US
Practice Address - Phone:580-562-4882
Practice Address - Fax:580-562-4880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251B00000X251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100680810AMedicaid