Healthcare Provider Details

I. General information

NPI: 1891028247
Provider Name (Legal Business Name): EQUESTRIAN CONNECTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2009
Last Update Date: 09/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N BRADLEY ROAD
LAKE FOREST IL
60045
US

IV. Provider business mailing address

872 S MILWAUKEE AVE #273
LIBERTYVILLE IL
60048-3227
US

V. Phone/Fax

Practice location:
  • Phone: 847-615-8696
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: DIANA SCHNELL
Title or Position: MANAGER
Credential:
Phone: 847-615-8696