Healthcare Provider Details

I. General information

NPI: 1215150537
Provider Name (Legal Business Name): DUNCAN COMMUNITY RESIDENCE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 11/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 W MAIN ST
DUNCAN OK
73533-4333
US

IV. Provider business mailing address

PO BOX 1474 1510 W. MAIN
DUNCAN OK
73534-1474
US

V. Phone/Fax

Practice location:
  • Phone: 580-255-3926
  • Fax: 580-255-8877
Mailing address:
  • Phone: 580-255-3926
  • Fax: 580-255-8877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License NumberRC6901-6901
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberRC6901-6901
License Number StateOK

VIII. Authorized Official

Name: MR. BRIAN D WOLFF
Title or Position: ADMINISTRATOR
Credential:
Phone: 580-255-3926