Provider Demographics
NPI:1417076001
Name:DCCCA, INC.
Entity Type:Organization
Organization Name:DCCCA, INC.
Other - Org Name:ELM ACRES RECOVERY-PITTSBURG OUTPATIENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KERYE
Authorized Official - Middle Name:J
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPA, CMA
Authorized Official - Phone:785-841-4138
Mailing Address - Street 1:3312 CLINTON PKWY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66047-3624
Mailing Address - Country:US
Mailing Address - Phone:785-841-4138
Mailing Address - Fax:785-841-5777
Practice Address - Street 1:1102 SOUTH ROUSE
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-6023
Practice Address - Country:US
Practice Address - Phone:620-231-5310
Practice Address - Fax:620-231-1178
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DCCCA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-28
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
KS052261QM0801X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No251B00000XAgenciesCase Management
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS116027OtherBLUE CROSS BLUE SHIELD
KS6250045OtherUNITED BEHAVIORAL HEALTH
KS100106740NMedicaid