1306279740 NPI number — MAPLE LAKE ASSISTED LIVING

Table of content: (NPI 1306279740)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306279740 NPI number — MAPLE LAKE ASSISTED LIVING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAPLE LAKE ASSISTED LIVING
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:
1306279740
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3196 KRAFT AVE SE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49512-2078
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-464-1564
Provider Business Mailing Address Fax Number:
616-464-2470

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
677 HAZEN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAW PAW
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49079-1010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-657-0190
Provider Business Practice Location Address Fax Number:
269-657-4290
Provider Enumeration Date:
08/20/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HALEY
Authorized Official First Name:
LINDSEY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
616-901-2986

Provider Taxonomy Codes

  • Taxonomy code: 302F00000X , with the licence number:  AH800315846 , 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)