Provider Demographics
NPI:1639225667
Name:JUDGE JAMES V RIDDEL BOYS RANCH
Entity Type:Organization
Organization Name:JUDGE JAMES V RIDDEL BOYS RANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CORRECTIONS
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-660-9750
Mailing Address - Street 1:700 S HYDRAULIC ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67211-2704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:316-660-1670
Practice Address - Street 1:25331 W 39TH ST S
Practice Address - Street 2:
Practice Address - City:GODDARD
Practice Address - State:KS
Practice Address - Zip Code:67052-9244
Practice Address - Country:US
Practice Address - Phone:316-660-1600
Practice Address - Fax:316-794-2061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0003181-001323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility