Provider Demographics
NPI:1932237492
Name:LAZY HORSE RANCH
Entity Type:Organization
Organization Name:LAZY HORSE RANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:SUPPLEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-826-2206
Mailing Address - Street 1:3651 E DOE RANCH RD
Mailing Address - Street 2:
Mailing Address - City:PEARCE
Mailing Address - State:AZ
Mailing Address - Zip Code:85625-6002
Mailing Address - Country:US
Mailing Address - Phone:520-826-2206
Mailing Address - Fax:
Practice Address - Street 1:3651 E DOE RANCH RD
Practice Address - Street 2:
Practice Address - City:PEARCE
Practice Address - State:AZ
Practice Address - Zip Code:85625-6002
Practice Address - Country:US
Practice Address - Phone:520-826-2206
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCSA06ADHS0188251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ075457OtherAHCCS