Healthcare Provider Details

I. General information

NPI: 1124475132
Provider Name (Legal Business Name): GRAND VALLEY EQUINE ASSISTED LEARNING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2016
Last Update Date: 05/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

979 25 RD
GRAND JUNCTION CO
81505-9778
US

IV. Provider business mailing address

PO BOX 308
FRUITA CO
81521-0308
US

V. Phone/Fax

Practice location:
  • Phone: 970-216-8723
  • Fax:
Mailing address:
  • Phone: 970-216-8723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC0012779
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number8986
License Number StateCO

VIII. Authorized Official

Name: JAY D. MULLER
Title or Position: CO-FOUINDER
Credential:
Phone: 970-216-8723