Provider Demographics
NPI:1417581125
Name:PETTY CREEK RANCH LLC
Entity Type:Organization
Organization Name:PETTY CREEK RANCH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:POLLARD
Authorized Official - Last Name:MORSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-254-4191
Mailing Address - Street 1:PO BOX 289
Mailing Address - Street 2:
Mailing Address - City:ALBERTON
Mailing Address - State:MT
Mailing Address - Zip Code:59820-0289
Mailing Address - Country:US
Mailing Address - Phone:406-722-3226
Mailing Address - Fax:
Practice Address - Street 1:2161 PETTY CREEK RD
Practice Address - Street 2:
Practice Address - City:ALBERTON
Practice Address - State:MT
Practice Address - Zip Code:59820-9401
Practice Address - Country:US
Practice Address - Phone:406-722-3226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children