Provider Demographics
NPI:1073081907
Name:BOUCK, ROSE MARIE
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:MARIE
Last Name:BOUCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12700 LINCOLN LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:GOWEN
Mailing Address - State:MI
Mailing Address - Zip Code:49326-9403
Mailing Address - Country:US
Mailing Address - Phone:231-580-4533
Mailing Address - Fax:616-712-6002
Practice Address - Street 1:12700 LINCOLN LAKE AVE
Practice Address - Street 2:
Practice Address - City:GOWEN
Practice Address - State:MI
Practice Address - Zip Code:49326
Practice Address - Country:US
Practice Address - Phone:231-580-4533
Practice Address - Fax:616-712-6002
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF410395782311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home