Provider Demographics
NPI:1679771430
Name:GOOD SAMARITAN BOYS RANCH
Entity Type:Organization
Organization Name:GOOD SAMARITAN BOYS RANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF INFORMATION TECHNOLOGY
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:MAINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-376-2238
Mailing Address - Street 1:PO BOX 617
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MO
Mailing Address - Zip Code:65617-0617
Mailing Address - Country:US
Mailing Address - Phone:417-376-2238
Mailing Address - Fax:
Practice Address - Street 1:5549 N HIGHWAY 13
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MO
Practice Address - Zip Code:65617-8112
Practice Address - Country:US
Practice Address - Phone:417-376-2238
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)