Healthcare Provider Details

I. General information

NPI: 1215223375
Provider Name (Legal Business Name): STORYRANCH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 06/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 MINERAL HILL
LAS VEGAS NM
87701
US

IV. Provider business mailing address

1300 MINERAL HILL
LAS VEGAS NM
87701
US

V. Phone/Fax

Practice location:
  • Phone: 505-425-5578
  • Fax:
Mailing address:
  • Phone: 505-425-5578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1590
License Number StateNM

VIII. Authorized Official

Name: MR. JOHN JAMES MCLEOD
Title or Position: PARTNER
Credential:
Phone: 505-425-5578