1053308734 NPI number — MAPLE MANOR NURSING CENTER, INC

Table of content: (NPI 1053308734)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053308734 NPI number — MAPLE MANOR NURSING CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAPLE MANOR NURSING CENTER, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053308734
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/07/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 VILLA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HURLEY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54534-1523
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-561-3200
Provider Business Mailing Address Fax Number:
715-561-5556

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 2ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ONTONAGON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49953-1337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-884-2882
Provider Business Practice Location Address Fax Number:
906-884-2885
Provider Enumeration Date:
09/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KUTZ
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
715-561-3200

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  664020 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2082408 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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