Healthcare Provider Details

I. General information

NPI: 1437595568
Provider Name (Legal Business Name): WHITE PINE BOYS RANCH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2013
Last Update Date: 05/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HC 34 BOX 34165
ELY NV
89301-9206
US

IV. Provider business mailing address

HC 34 BOX 34165
ELY NV
89301-9206
US

V. Phone/Fax

Practice location:
  • Phone: 775-238-5100
  • Fax: 775-238-5103
Mailing address:
  • Phone: 775-238-5100
  • Fax: 775-238-5103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number1389-13
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number1389-13
License Number StateNV

VIII. Authorized Official

Name: MR. LAWRENCE ALAN BRADLEY
Title or Position: EXECUTIVE DIRECTOR
Credential: M.A., LMFT
Phone: 775-238-5100