Healthcare Provider Details

I. General information

NPI: 1063624351
Provider Name (Legal Business Name): SPECIALIZED OUTPATIENT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5208 CLASSEN CIR
OKLAHOMA CITY OK
73118-4429
US

IV. Provider business mailing address

5208 CLASSEN CIR
OKLAHOMA CITY OK
73118-4429
US

V. Phone/Fax

Practice location:
  • Phone: 405-810-1766
  • Fax: 405-810-0331
Mailing address:
  • Phone: 405-810-1766
  • Fax: 405-810-0331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number291
License Number State

VIII. Authorized Official

Name: MR. MIKE JAMES MADDOX
Title or Position: ADOLESCENT PROGRAM DIRECTOR
Credential: CADC
Phone: 405-810-1766