Healthcare Provider Details

I. General information

NPI: 1629816582
Provider Name (Legal Business Name): AMAZING GRACE EQUINE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2024
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12956 N SLIDEOFF RD
CAMBY IN
46113-8595
US

IV. Provider business mailing address

12956 N SLIDEOFF RD
CAMBY IN
46113-8595
US

V. Phone/Fax

Practice location:
  • Phone: 317-518-2272
  • Fax:
Mailing address:
  • Phone: 317-518-2272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. BRITNEY ZIMMER
Title or Position: COO
Credential: DPT
Phone: 317-518-2272