Provider Demographics
NPI:1467470310
Name:ROADBACK INCORPORATED
Entity Type:Organization
Organization Name:ROADBACK INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICK
Authorized Official - Middle Name:DAN
Authorized Official - Last Name:PICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:BA, CADC
Authorized Official - Phone:580-357-8114
Mailing Address - Street 1:PO BOX 3198
Mailing Address - Street 2:405 SW 15TH
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73502-3198
Mailing Address - Country:US
Mailing Address - Phone:580-357-8114
Mailing Address - Fax:580-353-3854
Practice Address - Street 1:1202 SW A AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-3821
Practice Address - Country:US
Practice Address - Phone:580-357-6889
Practice Address - Fax:580-357-4390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility