Provider Demographics
NPI:1801649090
Name:RENAISSANCE RANCH IDAHO
Entity type:Organization
Organization Name:RENAISSANCE RANCH IDAHO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:ELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLESH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:385-321-0244
Mailing Address - Street 1:2973 W 13800 S
Mailing Address - Street 2:
Mailing Address - City:BLUFFDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84065-8202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1275 N 400 E APT F
Practice Address - Street 2:
Practice Address - City:RUPERT
Practice Address - State:ID
Practice Address - Zip Code:83350-8549
Practice Address - Country:US
Practice Address - Phone:801-545-0406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AWAKENING BEHAVIORAL HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility