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General NPI Number Information
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NPI Number | 1336329911
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Entity Type | Organization
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Legal Business Name | DCCCA, INC
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Dates
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Enumeration Date | 11/12/2007
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Last Update Date | 05/29/2020
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Provider Practice Location Address
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Address Line | 2110 KANSAS AVE
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City | GREAT BEND
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State | KS
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Zip | 67530-2516
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Country | US
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Telephone | 620-792-4665
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Fax | 620-792-2445
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Provider Business Mailing Address
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Address Line | 3312 CLINTON PKWY
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City | LAWRENCE
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State | KS
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Zip | 66047-3624
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Country | US
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Telephone | 785-841-4138
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Fax | 785-841-5777
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Authorized Official
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Title or Position | CFO
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Name | KERYE J. JACKLSON
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Credential | CPA, CMA, MBA
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Telephone | 785-841-4138
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | 678
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License Number State | KS
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