Provider Demographics
NPI:1104990373
Name:YELLOWSTONE BOYS AND GIRLS RANCH
Entity type:Organization
Organization Name:YELLOWSTONE BOYS AND GIRLS RANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAVERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-655-2109
Mailing Address - Street 1:1732 S 72ND ST W
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59106-3500
Mailing Address - Country:US
Mailing Address - Phone:406-655-2100
Mailing Address - Fax:406-651-2783
Practice Address - Street 1:1732 S 72ND ST W
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59106-3500
Practice Address - Country:US
Practice Address - Phone:406-655-2100
Practice Address - Fax:406-651-2783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2084P0804X, 364S00000X, 363LF0000X
MT10810323P00000X, 322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed ChildrenGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment FacilityGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4104880Medicaid