Provider Demographics
NPI:1710106778
Name:BROADWAY HOUSE, INC.
Entity Type:Organization
Organization Name:BROADWAY HOUSE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:WADONNA
Authorized Official - Middle Name:D
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:MHR, LADC
Authorized Official - Phone:580-226-3252
Mailing Address - Street 1:221 2ND AVE NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-6202
Mailing Address - Country:US
Mailing Address - Phone:580-226-3252
Mailing Address - Fax:580-226-3849
Practice Address - Street 1:221 2ND AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-6202
Practice Address - Country:US
Practice Address - Phone:580-226-3252
Practice Address - Fax:580-226-3849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility