Provider Demographics
NPI:1689834103
Name:ESTRELLA VISTA RANCH LLC
Entity Type:Organization
Organization Name:ESTRELLA VISTA RANCH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:TAHSE
Authorized Official - Last Name:PALACIOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-206-7687
Mailing Address - Street 1:PO BOX 235
Mailing Address - Street 2:
Mailing Address - City:DRAGOON
Mailing Address - State:AZ
Mailing Address - Zip Code:85609-0235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4911 EAST SILK WIND BLVD
Practice Address - Street 2:
Practice Address - City:DRAGOON
Practice Address - State:AZ
Practice Address - Zip Code:85609
Practice Address - Country:US
Practice Address - Phone:520-586-9254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-3062322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children