Provider Demographics
NPI:1528499696
Name:KLAMATH LAKE COUNTY YOUTH RANCH
Entity type:Organization
Organization Name:KLAMATH LAKE COUNTY YOUTH RANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-545-6742
Mailing Address - Street 1:5800 HAPPY HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:BONANZA
Mailing Address - State:OR
Mailing Address - Zip Code:97623-7714
Mailing Address - Country:US
Mailing Address - Phone:541-545-6742
Mailing Address - Fax:
Practice Address - Street 1:5800 HAPPY HOLLOW LN
Practice Address - Street 2:
Practice Address - City:BONANZA
Practice Address - State:OR
Practice Address - Zip Code:97623-7714
Practice Address - Country:US
Practice Address - Phone:541-545-6742
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-27
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0138322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children