Healthcare Provider Details

I. General information

NPI: 1730560608
Provider Name (Legal Business Name): TRIANGLE CROSS RANCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2015
Last Update Date: 06/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 ROAD 1AF
POWELL WY
82435-8103
US

IV. Provider business mailing address

428 ROAD 1AF
POWELL WY
82435-8103
US

V. Phone/Fax

Practice location:
  • Phone: 307-645-3322
  • Fax: 307-645-3030
Mailing address:
  • Phone: 307-645-3322
  • Fax: 307-645-3030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MICHAEL POLLARD MORSO
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 307-254-4191