Provider Demographics
NPI:1922744374
Name:EAGLE RANCH, INC.
Entity Type:Organization
Organization Name:EAGLE RANCH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WATTS
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:770-967-8500
Mailing Address - Street 1:PO BOX 7200
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30502-0050
Mailing Address - Country:US
Mailing Address - Phone:770-967-8500
Mailing Address - Fax:
Practice Address - Street 1:5500 UNION CHURCH RD
Practice Address - Street 2:
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-5216
Practice Address - Country:US
Practice Address - Phone:770-967-8500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)