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General NPI Number Information
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NPI Number | 1194208793
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Entity Type | Organization
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Legal Business Name | LAZY DOG RANCH , INC., A CALIFORNIA CORPORATION
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Dates
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Enumeration Date | 09/10/2018
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Last Update Date | 09/10/2018
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Provider Practice Location Address
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Address Line | 34247 YUCAIPA BLVD STE I
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City | YUCAIPA
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State | CA
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Zip | 92399-6118
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Country | US
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Telephone | 909-599-0871
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Fax | 909-494-5518
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Provider Business Mailing Address
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Address Line | PO BOX 1869
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City | YUCAIPA
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State | CA
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Zip | 92399-1452
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Country | US
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Telephone | 909-277-5045
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Fax | 909-494-5518
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Authorized Official
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Title or Position | ADMINISTRATOR/CO-OWNER
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Name | MS. CHRISTINE LOUISE GALLAGHER
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Credential | LPT
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Telephone | 909-277-5045
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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