Provider Demographics
NPI:1336348705
Name:SPRING LAKE RANCH
Entity Type:Organization
Organization Name:SPRING LAKE RANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDS-PEELLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-492-3322
Mailing Address - Street 1:1169 SPRING LAKE RD
Mailing Address - Street 2:
Mailing Address - City:CUTTINGSVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05738-4418
Mailing Address - Country:US
Mailing Address - Phone:802-492-3322
Mailing Address - Fax:802-492-3331
Practice Address - Street 1:1169 SPRING LAKE RD
Practice Address - Street 2:
Practice Address - City:CUTTINGSVILLE
Practice Address - State:VT
Practice Address - Zip Code:05738-4418
Practice Address - Country:US
Practice Address - Phone:802-492-3322
Practice Address - Fax:802-492-3331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0526320800000X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility