Provider Demographics
NPI:1568899243
Name:BOB BELLONI RANCH, INC.
Entity Type:Organization
Organization Name:BOB BELLONI RANCH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:LANGLIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-269-0321
Mailing Address - Street 1:320 CENTRAL AVE STE 406
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2241
Mailing Address - Country:US
Mailing Address - Phone:541-269-0321
Mailing Address - Fax:
Practice Address - Street 1:320 CENTRAL AVE STE 406
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2241
Practice Address - Country:US
Practice Address - Phone:541-269-0321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500400418Medicaid