Provider Demographics
NPI:1700904513
Name:DCCCA, INC
Entity Type:Organization
Organization Name:DCCCA, INC
Other - Org Name:DCCCA, INC OPTIONS ADULT
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 1:8901 E ORME ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67207-2473
Practice Address - Country:US
Practice Address - Phone:316-265-6011
Practice Address - Fax:316-265-4022
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DCCCA, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-27
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS074261QM0801X
261QR0405X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1246OtherBLUE CROSS BLUE SHIELD