Basic Information
| Provider Information | |||||||||
| NPI: | 1487723276 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN OKLAHOMA TREATMENT SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 512 E 24TH ST | ||||||||
| Address2: | |||||||||
| City: | TISHOMINGO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734603214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803713672 | ||||||||
| FaxNumber: | 5803713651 | ||||||||
| Practice Location | |||||||||
| Address1: | 715 N 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | DURANT | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747013801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809313008 | ||||||||
| FaxNumber: | 5809318022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 11/05/2009 | ||||||||
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| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | MILTON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5803713672 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 200049040 F | 05 | OK | MEDICAID |