Healthcare Provider Details

I. General information

NPI: 1639592082
Provider Name (Legal Business Name): FIVE SISTERS RANCH, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2014
Last Update Date: 01/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 LONGHORN LN
PETALUMA CA
94952-7808
US

IV. Provider business mailing address

PO BOX 5037
PETALUMA CA
94955-5037
US

V. Phone/Fax

Practice location:
  • Phone: 954-678-0078
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number490035AP
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number490035AP
License Number StateCA

VIII. Authorized Official

Name: MRS. NANCIE BROWN
Title or Position: DIRECTOR
Credential:
Phone: 954-678-0078