Provider Demographics
NPI:1467990721
Name:KIAMICHI COUNCIL ON ALCOHOISM AND OTHER DRUG ABUSE INC.
Entity Type:Organization
Organization Name:KIAMICHI COUNCIL ON ALCOHOISM AND OTHER DRUG ABUSE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DORTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-286-3301
Mailing Address - Street 1:PO BOX 689
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745
Mailing Address - Country:US
Mailing Address - Phone:580-286-3301
Mailing Address - Fax:580-286-6385
Practice Address - Street 1:104 NE AVE A
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745
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:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management