Basic Information
| Provider Information | |||||||||
| NPI: | 1548500614 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FALCON RIDGE RANCH NON PROFIT ORGANIZATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 790099 | ||||||||
| Address2: | |||||||||
| City: | VIRGIN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847790099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356355260 | ||||||||
| FaxNumber: | 4356730994 | ||||||||
| Practice Location | |||||||||
| Address1: | 633 E HWY 9 | ||||||||
| Address2: | |||||||||
| City: | VIRGIN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356355260 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2013 | ||||||||
| LastUpdateDate: | 06/24/2015 | ||||||||
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| AuthorizedOfficialLastName: | PACE | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4356736111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MA ED, MC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3245S0500X | 20004 | UT | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children | 323P00000X | 20004 | UT | Y | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
No ID Information.