Provider Demographics
NPI:1720501570
Name:YELLOWSTONE BOYS AND GIRLS RANCH
Entity Type:Organization
Organization Name:YELLOWSTONE BOYS AND GIRLS RANCH
Other - Org Name:CHEMICAL DEPENDENCY
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAVERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-655-2100
Mailing Address - Street 1:1700 S 72ND ST W
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59106-3538
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1732 S 72ND ST W
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59106
Practice Address - Country:US
Practice Address - Phone:406-655-2100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YELLOWSTONE BOYS AND GIRLS RANCH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-07-24
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT177854Medicaid
MT177762Medicaid