Basic Information
| Provider Information | |||||||||
| NPI: | 1710223326 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JIM TALIAFERRO COMMUNITY MENTAL HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 602 SW 38TH ST | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735056912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802485780 | ||||||||
| FaxNumber: | 5802501831 | ||||||||
| Practice Location | |||||||||
| Address1: | 602 SW 38TH ST | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802485780 | ||||||||
| FaxNumber: | 5802501831 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2012 | ||||||||
| LastUpdateDate: | 12/31/2012 | ||||||||
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| AuthorizedOfficialLastName: | DILLON | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OUTPATIENT SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 5802485780 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OKLAHOMA DEPARTMENT OF MENTAL HEALTH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
No ID Information.