Provider Demographics
NPI:1437595568
Name:WHITE PINE BOYS RANCH, LLC
Entity Type:Organization
Organization Name:WHITE PINE BOYS RANCH, LLC
Other - Org Name:HOME ON THE RANGE YOUTH RANCH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LMFT
Authorized Official - Phone:775-238-5100
Mailing Address - Street 1:HC 34 BOX 34165
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:NV
Mailing Address - Zip Code:89301-9206
Mailing Address - Country:US
Mailing Address - Phone:775-238-5100
Mailing Address - Fax:775-238-5103
Practice Address - Street 1:HC 34 BOX 34165
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:NV
Practice Address - Zip Code:89301-9206
Practice Address - Country:US
Practice Address - Phone:775-238-5100
Practice Address - Fax:775-238-5103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-15
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1389-13322D00000X, 3245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children