Provider Demographics
NPI:1891012092
Name:CHOCTAW NATION RECOVERY CENTER
Entity Type:Organization
Organization Name:CHOCTAW NATION RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:C
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MED, CM-D
Authorized Official - Phone:918-567-2389
Mailing Address - Street 1:RR 2 BOX 1600
Mailing Address - Street 2:
Mailing Address - City:TALIHINA
Mailing Address - State:OK
Mailing Address - Zip Code:74571-9516
Mailing Address - Country:US
Mailing Address - Phone:918-567-2389
Mailing Address - Fax:918-567-2417
Practice Address - Street 1:RR 2 BOX 1600
Practice Address - Street 2:13224 SE 202 RD
Practice Address - City:TALIHINA
Practice Address - State:OK
Practice Address - Zip Code:74571-9516
Practice Address - Country:US
Practice Address - Phone:918-567-2389
Practice Address - Fax:918-567-2417
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHOCTAW NATION HEALTH CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-27
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK344324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility