Provider Demographics
NPI:1861893547
Name:EAGLE VISTA EQUINE CENTER, INC.
Entity type:Organization
Organization Name:EAGLE VISTA EQUINE CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/FOUNDER AND LPC
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:LETSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:218-760-0656
Mailing Address - Street 1:16150 GOLDEN EAGLE CT NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-7111
Mailing Address - Country:US
Mailing Address - Phone:218-760-0656
Mailing Address - Fax:
Practice Address - Street 1:16150 GOLDEN EAGLE CT NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-7111
Practice Address - Country:US
Practice Address - Phone:218-760-0656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-11
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN01258251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health