Provider Demographics
NPI:1386237881
Name:FOSTERING LIFE YOUTH RANCH, LLC
Entity type:Organization
Organization Name:FOSTERING LIFE YOUTH RANCH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:M
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-703-1919
Mailing Address - Street 1:5109 82ND ST STE 7-1203
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-3028
Mailing Address - Country:US
Mailing Address - Phone:575-703-1919
Mailing Address - Fax:
Practice Address - Street 1:1515 5TH ST
Practice Address - Street 2:
Practice Address - City:LEVELLAND
Practice Address - State:TX
Practice Address - Zip Code:79336-3311
Practice Address - Country:US
Practice Address - Phone:575-703-1919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-16
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty