1306072780 NPI number — PROSPECT MOUNTAIN THERAPEUTIC RIDING CENTER

Table of content: (NPI 1306072780)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306072780 NPI number — PROSPECT MOUNTAIN THERAPEUTIC RIDING CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROSPECT MOUNTAIN THERAPEUTIC RIDING CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PMTRC
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306072780
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7471 FM 3094
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCURRY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75158-4915
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-595-2019
Provider Business Mailing Address Fax Number:
972-452-3331

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7471 FM 3094
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCURRY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75158-4915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-595-2019
Provider Business Practice Location Address Fax Number:
972-452-3331
Provider Enumeration Date:
05/30/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LISENBY
Authorized Official First Name:
THERESA
Authorized Official Middle Name:
RAE
Authorized Official Title or Position:
INSTRUCTOR, CEO
Authorized Official Telephone Number:
469-595-2019

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 252Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 320900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)