Provider Demographics
NPI:1033831599
Name:PALACE 1 THERAPEUTIC RANCH
Entity Type:Organization
Organization Name:PALACE 1 THERAPEUTIC RANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:WOOTEN-RUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-235-5443
Mailing Address - Street 1:PO BOX 2862
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75123-2862
Mailing Address - Country:US
Mailing Address - Phone:469-235-5443
Mailing Address - Fax:
Practice Address - Street 1:2115 MESA WOOD DR
Practice Address - Street 2:
Practice Address - City:GLENN HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:75154-8583
Practice Address - Country:US
Practice Address - Phone:469-235-5443
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PALACE 1 ART DAY HAB
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX32072801361OtherTAXPAYER NUMBER