Provider Demographics
NPI:1174647663
Name:YELLOWSTONE BOYS AND GIRLS RANCH
Entity Type:Organization
Organization Name:YELLOWSTONE BOYS AND GIRLS RANCH
Other - Org Name:TARGETED CASE MANAGEMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAVERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-655-2109
Mailing Address - Street 1:1732 S 72ND ST W
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59106-3538
Mailing Address - Country:US
Mailing Address - Phone:406-655-2100
Mailing Address - Fax:406-651-2783
Practice Address - Street 1:1732 S 72ND ST W
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59106-3538
Practice Address - Country:US
Practice Address - Phone:406-655-2100
Practice Address - Fax:406-651-2783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT11000251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0290377Medicaid