Healthcare Provider Details

I. General information

NPI: 1285398024
Provider Name (Legal Business Name): EQUILIBRIUM RANCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2021
Last Update Date: 01/03/2025
Certification Date: 01/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 PILKENTON LN
CUBA MO
65453-8136
US

IV. Provider business mailing address

81 PILKENTON LN
CUBA MO
65453-8136
US

V. Phone/Fax

Practice location:
  • Phone: 573-885-6443
  • Fax: 844-851-0578
Mailing address:
  • Phone: 573-885-6443
  • Fax: 844-851-0578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code364SL0600X
TaxonomyLong-Term Care Clinical Nurse Specialist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name: CHRISTIAN B SHELTON
Title or Position: OWNER
Credential:
Phone: 314-580-3029