Provider Demographics
NPI:1043377708
Name:ST. JUDE'S RANCH FOR CHILDREN
Entity Type:Organization
Organization Name:ST. JUDE'S RANCH FOR CHILDREN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESIDENTIAL COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:GANT
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:702-294-7101
Mailing Address - Street 1:PO BOX 60100
Mailing Address - Street 2:
Mailing Address - City:BOULDER CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89006-0100
Mailing Address - Country:US
Mailing Address - Phone:702-294-7101
Mailing Address - Fax:702-294-7191
Practice Address - Street 1:100 SAINT JUDES ST
Practice Address - Street 2:
Practice Address - City:BOULDER CITY
Practice Address - State:NV
Practice Address - Zip Code:89005-1614
Practice Address - Country:US
Practice Address - Phone:702-294-7101
Practice Address - Fax:702-294-7191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVC3701994322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children