Basic Information
Provider Information | |||||||||
NPI: | 1194048298 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MAPLE LANE HEALTH & REHABILITATION CENTER LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | D/B/A ATRIUM POST ACUTE CARE OF SHAWANO AT MAPLE LANE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1726 N BALLARD RD | ||||||||
Address2: |   | ||||||||
City: | APPLETON | ||||||||
State: | WI | ||||||||
PostalCode: | 549112444 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9209919072 | ||||||||
FaxNumber: | 9207494022 | ||||||||
Practice Location | |||||||||
Address1: | N4231 STATE HIGHWAY 22 | ||||||||
Address2: |   | ||||||||
City: | SHAWANO | ||||||||
State: | WI | ||||||||
PostalCode: | 541666130 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7155263158 | ||||||||
FaxNumber: | 7155266823 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/04/2010 | ||||||||
LastUpdateDate: | 05/27/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PARKINS | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 9203649754 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 2579 | WI | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.