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General NPI Number Information
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NPI Number | 1881424224
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Entity Type | Organization
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Legal Business Name | PHILLIPS RANCH, LLC
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Dates
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Enumeration Date | 08/01/2024
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Last Update Date | 01/22/2025
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Provider Practice Location Address
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Address Line | 3067 MOSQUITO CREEK RD
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City | CLARK FORK
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State | ID
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Zip | 83811-9825
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Country | US
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Telephone | 720-495-0550
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Fax |
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Provider Business Mailing Address
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Address Line | 640 CHAMPS RD
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City | BONNERS FERRY
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State | ID
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Zip | 83805-6219
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Country | US
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Telephone | 720-495-0550
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Fax |
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Authorized Official
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Title or Position | OWNER/CLINICAL DIRECTOR
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Name | MRS. ALISON GRACE AGGEN
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Credential | LPCC
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Telephone | 720-495-0550
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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