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NPI Code Detail

MEDICARE: ST. JUDE'S RANCH FOR CHILDREN

MEDICARE: ST. JUDE'S RANCH FOR CHILDREN
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1322D00000XEmotionally Disturbed Childrens' Residential Treatment FacilityC3701994NV

General Provider Information

NPI Number : 1043377708
Entity Type Code : Organization
Provider Name (Legal Business Name) : ST. JUDE'S RANCH FOR CHILDREN
Provider Business Mailing Address
First Line : PO BOX 60100
Second Line :
City : BOULDER CITY
State : NV
Zip : 89006-0100
Country : US
Telephone Number : 702-294-7101
Fax Number : 702-294-7191
Provider Business Practice Location Address
First Line : 100 SAINT JUDES ST
Second Line :
City : BOULDER CITY
State : NV
Zip : 89005-1614
Country : US
Telephone Number : 702-294-7101
Fax Number : 702-294-7191
Authorized Official
Title or Position : RESIDENTIAL COORDINATOR
Name : MR. ROLAND CHARLES GANT JR.
Credential :
Telephone Number : 702-294-7101
Provider Enumeration Date : 01/02/2007
Last Update Date : 08/22/2020

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Directions to “ST. JUDE'S RANCH FOR CHILDREN ” Practice Location

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