Healthcare Provider Details

I. General information

NPI: 1194208793
Provider Name (Legal Business Name): LAZY DOG RANCH , INC., A CALIFORNIA CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2018
Last Update Date: 09/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34247 YUCAIPA BLVD STE I
YUCAIPA CA
92399-6118
US

IV. Provider business mailing address

PO BOX 1869
YUCAIPA CA
92399-1452
US

V. Phone/Fax

Practice location:
  • Phone: 909-599-0871
  • Fax: 909-494-5518
Mailing address:
  • Phone: 909-277-5045
  • Fax: 909-494-5518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. CHRISTINE LOUISE GALLAGHER
Title or Position: ADMINISTRATOR/CO-OWNER
Credential: LPT
Phone: 909-277-5045