Healthcare Provider Details

I. General information

NPI: 1710106778
Provider Name (Legal Business Name): BROADWAY HOUSE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 2ND AVE NW
ARDMORE OK
73401-6202
US

IV. Provider business mailing address

221 2ND AVE NW
ARDMORE OK
73401-6202
US

V. Phone/Fax

Practice location:
  • Phone: 580-226-3252
  • Fax: 580-226-3849
Mailing address:
  • Phone: 580-226-3252
  • Fax: 580-226-3849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. WADONNA D WELLS
Title or Position: EXECUTIVE DIRECTOR
Credential: MHR, LADC
Phone: 580-226-3252