Healthcare Provider Details

I. General information

NPI: 1114692373
Provider Name (Legal Business Name): RENAISSANCE RANCH HEYBURN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 S 950 W
HEYBURN ID
83336-9765
US

IV. Provider business mailing address

312 S 950 W
HEYBURN ID
83336-9765
US

V. Phone/Fax

Practice location:
  • Phone: 855-736-7262
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: TYSON BLAINE DIXON
Title or Position: OWNER
Credential:
Phone: 801-860-0118