Provider Demographics
NPI:1871870303
Name:MID-MICHIGAN EQUESTRIAN CENTER, INC.
Entity type:Organization
Organization Name:MID-MICHIGAN EQUESTRIAN CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:OCONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-258-5437
Mailing Address - Street 1:5629 WAY RD NW
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49676-9546
Mailing Address - Country:US
Mailing Address - Phone:231-258-5437
Mailing Address - Fax:231-258-6770
Practice Address - Street 1:5629 WAY RD NW
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:MI
Practice Address - Zip Code:49676-9546
Practice Address - Country:US
Practice Address - Phone:231-258-5437
Practice Address - Fax:231-258-6770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-11
Last Update Date:2011-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL1774963225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI772-855Medicaid