Provider Demographics
NPI:1740771195
Name:RIVERWALK RANCH, LLC
Entity Type:Organization
Organization Name:RIVERWALK RANCH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:JANEIRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-720-9525
Mailing Address - Street 1:6960 DICK PRICE ROAD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063
Mailing Address - Country:US
Mailing Address - Phone:850-491-4993
Mailing Address - Fax:
Practice Address - Street 1:6960 DICK PRICE ROAD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063
Practice Address - Country:US
Practice Address - Phone:817-720-9520
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-22
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility