Provider Demographics
NPI:1407972847
Name:KIAMICHI COUNCIL ON ALCOHOLISM AND OR OTHER DRUG ABUSE, INC.
Entity Type:Organization
Organization Name:KIAMICHI COUNCIL ON ALCOHOLISM AND OR OTHER DRUG ABUSE, INC.
Other - Org Name:KIAMICHI COUNCIL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DORTHEA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WHITTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-286-3301
Mailing Address - Street 1:P.O. BOX 689
Mailing Address - Street 2:104 NE AVENUE A
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-0689
Mailing Address - Country:US
Mailing Address - Phone:580-286-3301
Mailing Address - Fax:580-286-6385
Practice Address - Street 1:104 N.E. AVE. A
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-0689
Practice Address - Country:US
Practice Address - Phone:580-286-3301
Practice Address - Fax:580-286-6385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health