Provider Demographics
NPI:1700540515
Name:ROOTS ADOLESCENT RENEWAL RANCH
Entity Type:Organization
Organization Name:ROOTS ADOLESCENT RENEWAL RANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDIBURGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-999-8529
Mailing Address - Street 1:819 INDIAN TRL
Mailing Address - Street 2:
Mailing Address - City:ARGYLE
Mailing Address - State:TX
Mailing Address - Zip Code:76226-6831
Mailing Address - Country:US
Mailing Address - Phone:888-399-0489
Mailing Address - Fax:
Practice Address - Street 1:819 INDIAN TRL
Practice Address - Street 2:
Practice Address - City:ARGYLE
Practice Address - State:TX
Practice Address - Zip Code:76226-6831
Practice Address - Country:US
Practice Address - Phone:888-399-0489
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-27
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children