Healthcare Provider Details

I. General information

NPI: 1871191569
Provider Name (Legal Business Name): OLD OAK RANCH RECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2020
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19401 SUSAN WAY
SONORA CA
95370-9266
US

IV. Provider business mailing address

19401 SUSAN WAY
SONORA CA
95370-9266
US

V. Phone/Fax

Practice location:
  • Phone: 209-588-6071
  • Fax:
Mailing address:
  • Phone: 209-588-7018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER H KHAN
Title or Position: PRESIDENT
Credential:
Phone: 209-588-6164