Provider Demographics
NPI:1912494527
Name:EQUESTRIAN ZONE
Entity Type:Organization
Organization Name:EQUESTRIAN ZONE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:KUSTURIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:479-970-8351
Mailing Address - Street 1:PO BOX 282
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-0282
Mailing Address - Country:US
Mailing Address - Phone:479-970-8351
Mailing Address - Fax:479-967-1178
Practice Address - Street 1:4800 S FRANKFORT AVE
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72802-0823
Practice Address - Country:US
Practice Address - Phone:479-970-8351
Practice Address - Fax:479-967-1178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities