Provider Demographics
NPI:1699159400
Name:BRISTLECONE FAMILY RESOOURCES
Entity type:Organization
Organization Name:BRISTLECONE FAMILY RESOOURCES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:OTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-954-1400
Mailing Address - Street 1:704 MILL ST
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1321
Mailing Address - Country:US
Mailing Address - Phone:775-954-1400
Mailing Address - Fax:775-954-1406
Practice Address - Street 1:704 MILL ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1321
Practice Address - Country:US
Practice Address - Phone:775-954-1400
Practice Address - Fax:775-954-1406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-13
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7663ADA-1324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1457515850Medicaid