Provider Demographics
NPI:1508449372
Name:FAIRUZA ZAN TRUST
Entity Type:Organization
Organization Name:FAIRUZA ZAN TRUST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:IRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:901-870-1246
Mailing Address - Street 1:6569 HIGHWAY 305 N
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-3044
Mailing Address - Country:US
Mailing Address - Phone:901-870-1246
Mailing Address - Fax:
Practice Address - Street 1:6569 HIGHWAY 305 N
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-3044
Practice Address - Country:US
Practice Address - Phone:901-870-1246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-29
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01820347Medicaid