Basic Information
| Provider Information | |||||||||
| NPI: | 1487195665 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHEAST LEASING CO., LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MAPLE WOOD HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 724 NE 79TH TER | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641181564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164368940 | ||||||||
| FaxNumber: | 8134369289 | ||||||||
| Practice Location | |||||||||
| Address1: | 724 NE 79TH TER | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641181564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164368940 | ||||||||
| FaxNumber: | 8134369289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2017 | ||||||||
| LastUpdateDate: | 03/20/2017 | ||||||||
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| AuthorizedOfficialLastName: | STOLTZ | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5135301613 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.