Organization
FAIRUZA ZAN TRUST
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. IRIS GRAY OTR/L (CEO)
(901) 870-1246
Entity
Organization
Contact information
Practice address
6569 HIGHWAY 305 N, OLIVE BRANCH, MS 38654-3044
(901) 870-1246
Mailing address
6569 HIGHWAY 305 N, OLIVE BRANCH, MS 38654-3044
(901) 870-1246
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
—
—
252Y00000X
Early Intervention Provider Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01820347
—
MS
Enumeration date
04/29/2021
Last updated
09/08/2023
Update your record
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