Healthcare Provider Details

I. General information

NPI: 1477174936
Provider Name (Legal Business Name): EL RANCHO DE LA VIDA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2020
Last Update Date: 05/06/2020
Certification Date: 05/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 PAGE TERRACE
FAIRFIELD ME
04944
US

IV. Provider business mailing address

PO BOX 1
HINCKLEY ME
04944-0001
US

V. Phone/Fax

Practice location:
  • Phone: 207-387-0101
  • Fax:
Mailing address:
  • Phone: 207-387-0101
  • 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: BENJAMIN SMITH
Title or Position: OPERATIONS DIRECTOR
Credential:
Phone: 207-387-0101