Provider Demographics
NPI:1063624351
Name:SPECIALIZED OUTPATIENT SERVICES
Entity type:Organization
Organization Name:SPECIALIZED OUTPATIENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADOLESCENT PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MADDOX
Authorized Official - Suffix:
Authorized Official - Credentials:CADC
Authorized Official - Phone:405-810-1766
Mailing Address - Street 1:5208 CLASSEN CIR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-4429
Mailing Address - Country:US
Mailing Address - Phone:405-810-1766
Mailing Address - Fax:405-810-0331
Practice Address - Street 1:5208 CLASSEN CIR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-4429
Practice Address - Country:US
Practice Address - Phone:405-810-1766
Practice Address - Fax:405-810-0331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
291251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health