Healthcare Provider Details

I. General information

NPI: 1336329911
Provider Name (Legal Business Name): DCCCA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2007
Last Update Date: 05/29/2020
Certification Date: 05/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 KANSAS AVE
GREAT BEND KS
67530-2516
US

IV. Provider business mailing address

3312 CLINTON PKWY
LAWRENCE KS
66047-3624
US

V. Phone/Fax

Practice location:
  • Phone: 620-792-4665
  • Fax: 620-792-2445
Mailing address:
  • Phone: 785-841-4138
  • Fax: 785-841-5777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number678
License Number StateKS

VIII. Authorized Official

Name: KERYE J. JACKLSON
Title or Position: CFO
Credential: CPA, CMA, MBA
Phone: 785-841-4138