Provider Demographics
NPI:1881424224
Name:PHILLIPS RANCH, LLC
Entity type:Organization
Organization Name:PHILLIPS RANCH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALISON
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:AGGEN
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:720-495-0550
Mailing Address - Street 1:640 CHAMPS RD
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-6219
Mailing Address - Country:US
Mailing Address - Phone:720-495-0550
Mailing Address - Fax:
Practice Address - Street 1:3067 MOSQUITO CREEK RD
Practice Address - Street 2:
Practice Address - City:CLARK FORK
Practice Address - State:ID
Practice Address - Zip Code:83811-9825
Practice Address - Country:US
Practice Address - Phone:720-495-0550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-01
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility