Healthcare Provider Details

I. General information

NPI: 1346428109
Provider Name (Legal Business Name): HORSE HOLIDAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2008
Last Update Date: 02/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 ULSH GAP RD
MC CLURE PA
17841-8217
US

IV. Provider business mailing address

1919 ULSH GAP RD
MC CLURE PA
17841-8217
US

V. Phone/Fax

Practice location:
  • Phone: 570-658-3861
  • Fax:
Mailing address:
  • Phone: 570-658-3861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MS. ROSALEE FOREMAN
Title or Position: FOUNDER/PROGRAM DESIGNER
Credential:
Phone: 570-658-3861