Provider Demographics
NPI:1609015783
Name:ELM RANCH 1 LLC
Entity Type:Organization
Organization Name:ELM RANCH 1 LLC
Other - Org Name:ELM RANCH 1
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDUARDO
Authorized Official - Middle Name:P
Authorized Official - Last Name:BALTAZAR
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:916-293-1500
Mailing Address - Street 1:7104 SANTA JUANITA AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGEVALE
Mailing Address - State:CA
Mailing Address - Zip Code:95662-2832
Mailing Address - Country:US
Mailing Address - Phone:916-293-1500
Mailing Address - Fax:916-987-1593
Practice Address - Street 1:9048 ELM AVE
Practice Address - Street 2:
Practice Address - City:ORANGEVALE
Practice Address - State:CA
Practice Address - Zip Code:95662-3524
Practice Address - Country:US
Practice Address - Phone:916-987-2954
Practice Address - Fax:916-987-1593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-12
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities