Provider Demographics
NPI:1114692373
Name:RENAISSANCE RANCH HEYBURN
Entity Type:Organization
Organization Name:RENAISSANCE RANCH HEYBURN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TYSON
Authorized Official - Middle Name:BLAINE
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-860-0118
Mailing Address - Street 1:312 S 950 W
Mailing Address - Street 2:
Mailing Address - City:HEYBURN
Mailing Address - State:ID
Mailing Address - Zip Code:83336-9765
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:312 S 950 W
Practice Address - Street 2:
Practice Address - City:HEYBURN
Practice Address - State:ID
Practice Address - Zip Code:83336-9765
Practice Address - Country:US
Practice Address - Phone:855-736-7262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility