MEDICARE: RANCHO RECOVERY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1700560695
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RANCHO RECOVERY LLC

Provider Business Mailing Address
First Line	:	333 E ARROW HWY UNIT 220
Second Line	:
City	:	UPLAND
State	:	CA
Zip	:	91785-7008
Country	:	US
Telephone Number	:	909-476-2023
Fax Number	:	909-697-2900

Provider Business Practice Location Address
First Line	:	13684 JEREMY CT
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91739-2031
Country	:	US
Telephone Number	:	909-476-2023
Fax Number	:	909-697-2900

Authorized Official
Title or Position	:	CONTROLLER
Name	:	SAMUEL PHILLIPS
Credential	:
Telephone Number	:	909-292-6827

Provider Enumeration Date	:	06/12/2023
Last Update Date	:	06/12/2023

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