Provider Demographics
NPI:1295191260
Name:VALLEY TEEN RANCH
Entity Type:Organization
Organization Name:VALLEY TEEN RANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:CLENDENAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-437-1144
Mailing Address - Street 1:2610 W SHAW LN STE 105
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-2775
Mailing Address - Country:US
Mailing Address - Phone:559-437-1144
Mailing Address - Fax:559-438-5004
Practice Address - Street 1:10535 ROAD 35
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93636-8487
Practice Address - Country:US
Practice Address - Phone:559-437-1144
Practice Address - Fax:559-438-5004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-06
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA200001AN261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder