Healthcare Provider Details

I. General information

NPI: 1063827749
Provider Name (Legal Business Name): KW LEGACY RANCH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2014
Last Update Date: 06/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 SR 318
HIKO NV
89017-2215
US

IV. Provider business mailing address

HC 61 BOX 87
HIKO NV
89017-9635
US

V. Phone/Fax

Practice location:
  • Phone: 775-725-3900
  • Fax:
Mailing address:
  • Phone: 775-725-3900
  • Fax: 775-725-3925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number StateNV

VIII. Authorized Official

Name: LUKE HATCH
Title or Position: EXECUTIVE DIRECTOR
Credential: LCSW
Phone: 775-725-3900