Healthcare Provider Details

I. General information

NPI: 1578277737
Provider Name (Legal Business Name): WARDOG RANCH REINS OF CHANGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2023
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 E ABRIENDO AVE
PUEBLO CO
81004-4212
US

IV. Provider business mailing address

313 E ABRIENDO AVE
PUEBLO CO
81004-4212
US

V. Phone/Fax

Practice location:
  • Phone: 760-449-0367
  • Fax:
Mailing address:
  • Phone: 760-449-0367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY WARFIELD
Title or Position: CEO
Credential:
Phone: 760-449-0367