Basic Information
| Provider Information | |||||||||
| NPI: | 1114404530 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PB OUTPATIENT SERVICES TENNESSEE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE RANCH TENNESSEE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 207816 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753207816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473294100 | ||||||||
| FaxNumber: | 8473294900 | ||||||||
| Practice Location | |||||||||
| Address1: | 6275 PINEWOOD RD | ||||||||
| Address2: | |||||||||
| City: | NUNNELLY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371372523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317299728 | ||||||||
| FaxNumber: | 9317299632 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2018 | ||||||||
| LastUpdateDate: | 03/07/2022 | ||||||||
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| AuthorizedOfficialLastName: | SASSERSON | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9319948001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 323P00000X | N | Residential Treatment Facilities | Psychiatric Residential Treatment Facility | 324500000X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.