Healthcare Provider Details

I. General information

NPI: 1982161402
Provider Name (Legal Business Name): HORSE-PLAY OUTDOOR CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2019
Last Update Date: 02/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 GRANT AVE
PRAIRIE GROVE AR
72753-8417
US

IV. Provider business mailing address

902 GRANT AVE
PRAIRIE GROVE AR
72753-8417
US

V. Phone/Fax

Practice location:
  • Phone: 479-283-7899
  • Fax:
Mailing address:
  • Phone: 479-283-7899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SARA RUCKENBROD
Title or Position: EXECUTIVE DIRECTOR
Credential: DPT
Phone: 479-283-7899