Provider Demographics
NPI:1255744454
Name:CROCKETT RANCH THERAPY SERVICES
Entity type:Organization
Organization Name:CROCKETT RANCH THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:928-853-9843
Mailing Address - Street 1:11705 N US HIGHWAY 89
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-5327
Mailing Address - Country:US
Mailing Address - Phone:928-853-9843
Mailing Address - Fax:
Practice Address - Street 1:11705 N US HIGHWAY 89
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-5327
Practice Address - Country:US
Practice Address - Phone:928-853-9843
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine