Provider Demographics
NPI:1689814063
Name:ROCKING HORSE RANCH AFC HOME
Entity Type:Organization
Organization Name:ROCKING HORSE RANCH AFC HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MOONYEEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:LINCOLN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-846-6593
Mailing Address - Street 1:19138 144TH AVE
Mailing Address - Street 2:
Mailing Address - City:FRUITPORT
Mailing Address - State:MI
Mailing Address - Zip Code:49415-9670
Mailing Address - Country:US
Mailing Address - Phone:616-846-6593
Mailing Address - Fax:
Practice Address - Street 1:19138 144TH AVE
Practice Address - Street 2:
Practice Address - City:FRUITPORT
Practice Address - State:MI
Practice Address - Zip Code:49415-9670
Practice Address - Country:US
Practice Address - Phone:616-846-6593
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-25
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF700237485320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities