1144405804 NPI number — SNOWSHOE LTC GROUP, LLC

Table of content: (NPI 1144405804)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144405804 NPI number — SNOWSHOE LTC GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SNOWSHOE LTC GROUP, LLC
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:
MAPLE GROVE HEALTH AND REHABILITATION CENTER
Provider Other Organization Name Type Code:
3
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:
1144405804
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
308 W MEADOWVIEW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27406-3610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-230-0534
Provider Business Mailing Address Fax Number:
336-230-1664

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
308 W MEADOWVIEW RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27406-3610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-230-0534
Provider Business Practice Location Address Fax Number:
336-230-1664
Provider Enumeration Date:
12/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BOICE
Authorized Official First Name:
GALE
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
252-523-9094

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X , with the licence number:  NH0552 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 313M00000X , with the licence number: NH0552 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 7806638 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7802688 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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