Provider Demographics
NPI:1922342336
Name:IRONHEAD RANCH, INC.
Entity Type:Organization
Organization Name:IRONHEAD RANCH, INC.
Other - Org Name:DESOTO CARE, ALF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EVA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LOWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-491-0748
Mailing Address - Street 1:PO BOX 575
Mailing Address - Street 2:
Mailing Address - City:NOCATEE
Mailing Address - State:FL
Mailing Address - Zip Code:34268-0575
Mailing Address - Country:US
Mailing Address - Phone:863-494-2552
Mailing Address - Fax:863-491-0748
Practice Address - Street 1:1711 SW COUNTY RD 760A
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:FL
Practice Address - Zip Code:34266
Practice Address - Country:US
Practice Address - Phone:863-494-2552
Practice Address - Fax:863-491-0748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11052310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL679652400Medicaid