Provider Demographics
NPI:1992179253
Name:NORTH IDAHO RANCH RECOVERY CLINIC
Entity Type:Organization
Organization Name:NORTH IDAHO RANCH RECOVERY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GMP
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-755-5200
Mailing Address - Street 1:4570 S STACH RD
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-7955
Mailing Address - Country:US
Mailing Address - Phone:208-755-5200
Mailing Address - Fax:805-991-9866
Practice Address - Street 1:4570 S STACH RD
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-7955
Practice Address - Country:US
Practice Address - Phone:208-755-5200
Practice Address - Fax:805-991-9866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-23
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility