Healthcare Provider Details

I. General information

NPI: 1467470310
Provider Name (Legal Business Name): ROADBACK INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 SW A AVE
LAWTON OK
73501-3821
US

IV. Provider business mailing address

PO BOX 3198 405 SW 15TH
LAWTON OK
73502-3198
US

V. Phone/Fax

Practice location:
  • Phone: 580-357-6889
  • Fax: 580-357-4390
Mailing address:
  • Phone: 580-357-8114
  • Fax: 580-353-3854

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: RICK DAN PICKENS
Title or Position: EXECUTIVE DIRECTOR
Credential: BA, CADC
Phone: 580-357-8114