Basic Information
| Provider Information | |||||||||
| NPI: | 1184020612 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAPLE MANOR NURSING AND REHAB LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8170 MCCORMICK BLVD | ||||||||
| Address2: | STE 112 | ||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600762961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738253336 | ||||||||
| FaxNumber: | 7735704554 | ||||||||
| Practice Location | |||||||||
| Address1: | 1875 19TH ST NW | ||||||||
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| City: | ROCHESTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559011633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072829449 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2014 | ||||||||
| LastUpdateDate: | 09/16/2020 | ||||||||
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| AuthorizedOfficialLastName: | STESEL | ||||||||
| AuthorizedOfficialFirstName: | MAX | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 7738253336 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 843242200 | 05 | MN | MEDICAID |