=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215488325
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RANCH FOR KIDS PROJECT, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2016
-----------------------------------------------------
Last Update Date | 03/22/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 144 GATEWAY STREET
-----------------------------------------------------
City | REXFORD
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-297-7592
-----------------------------------------------------
Fax | 406-297-7592
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 116
-----------------------------------------------------
City | REXFORD
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59930-0116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-297-7592
-----------------------------------------------------
Fax | 406-297-7592
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. WILLIAM J SUTLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 406-250-0464
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | PAP-PAP-LIC-580
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------