Provider Demographics
NPI:1306272091
Name:WISDOM RANCH
Entity type:Organization
Organization Name:WISDOM RANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DELENA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-650-4084
Mailing Address - Street 1:11009 FOLEY ROAD
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:MI
Mailing Address - Zip Code:48022
Mailing Address - Country:US
Mailing Address - Phone:810-650-4084
Mailing Address - Fax:
Practice Address - Street 1:11009 FOLEY RD
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:MI
Practice Address - Zip Code:48022-2004
Practice Address - Country:US
Practice Address - Phone:810-650-4084
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-25
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health