Provider Demographics
NPI:1285979583
Name:RANAISSANCE RANCH OUTPATIENT TREATMENT
Entity type:Organization
Organization Name:RANAISSANCE RANCH OUTPATIENT TREATMENT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:V
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:I
Authorized Official - Credentials:
Authorized Official - Phone:801-326-9173
Mailing Address - Street 1:9160 S 300 W STE 13
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-2656
Mailing Address - Country:US
Mailing Address - Phone:801-571-4325
Mailing Address - Fax:
Practice Address - Street 1:9160 S 300 W STE 13
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-2656
Practice Address - Country:US
Practice Address - Phone:801-571-4325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-28
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6253804-3501261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health