Provider Demographics
NPI:1023322492
Name:HISTORIC PINES YOUTH RANCH LLC
Entity type:Organization
Organization Name:HISTORIC PINES YOUTH RANCH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:PECK
Authorized Official - Last Name:KANE
Authorized Official - Suffix:
Authorized Official - Credentials:HMC
Authorized Official - Phone:702-430-6206
Mailing Address - Street 1:PO BOX 311
Mailing Address - Street 2:
Mailing Address - City:WESTCLIFFE
Mailing Address - State:CO
Mailing Address - Zip Code:81252-0311
Mailing Address - Country:US
Mailing Address - Phone:801-735-5971
Mailing Address - Fax:775-549-8800
Practice Address - Street 1:379 CHALICE DRIVE
Practice Address - Street 2:
Practice Address - City:WESTCLIFFE
Practice Address - State:CO
Practice Address - Zip Code:81252
Practice Address - Country:US
Practice Address - Phone:801-735-5971
Practice Address - Fax:775-549-8800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty