Healthcare Provider Details

I. General information

NPI: 1649502923
Provider Name (Legal Business Name): LAZY HORSE RANCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2010
Last Update Date: 02/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 N MADISON AVE
BENSON AZ
85602-6004
US

IV. Provider business mailing address

3651 E DOE RANCH RD
PEARCE AZ
85625-6002
US

V. Phone/Fax

Practice location:
  • Phone: 520-826-2206
  • Fax:
Mailing address:
  • Phone: 520-826-2206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberCSA09ADHS0188 2
License Number StateAZ

VIII. Authorized Official

Name: MRS. ANN M SUPPLEE
Title or Position: DIRECTOR
Credential: BHT
Phone: 520-826-2206