Provider Demographics
NPI:1780939223
Name:JACK BROWN TREATMENT CENTER
Entity type:Organization
Organization Name:JACK BROWN TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:DRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-453-5519
Mailing Address - Street 1:PO BOX 397
Mailing Address - Street 2:
Mailing Address - City:PARK HILL
Mailing Address - State:OK
Mailing Address - Zip Code:74451-0397
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17091 S MUSKOGEE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74465
Practice Address - Country:US
Practice Address - Phone:918-453-5501
Practice Address - Fax:918-458-0499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-20
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children