Provider Demographics
NPI:1639807324
Name:FREEDOM GATES BOYS RANCH
Entity Type:Organization
Organization Name:FREEDOM GATES BOYS RANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FISCAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:FREITAG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-239-4031
Mailing Address - Street 1:PO BOX 103
Mailing Address - Street 2:
Mailing Address - City:KIOWA
Mailing Address - State:KS
Mailing Address - Zip Code:67070-0103
Mailing Address - Country:US
Mailing Address - Phone:620-239-4031
Mailing Address - Fax:620-239-4032
Practice Address - Street 1:304 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:HAZELTON
Practice Address - State:KS
Practice Address - Zip Code:67061-9300
Practice Address - Country:US
Practice Address - Phone:620-239-4031
Practice Address - Fax:620-239-4032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1548479223Medicaid