Provider Demographics
NPI:1871191569
Name:OLD OAK RANCH RECOVERY CENTER
Entity Type:Organization
Organization Name:OLD OAK RANCH RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-588-6071
Mailing Address - Street 1:19401 SUSAN WAY
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-9266
Mailing Address - Country:US
Mailing Address - Phone:209-588-6071
Mailing Address - Fax:
Practice Address - Street 1:19401 SUSAN WAY
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-9266
Practice Address - Country:US
Practice Address - Phone:209-588-6071
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-14
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility