Basic Information
| Provider Information | |||||||||
| NPI: | 1487600052 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EXTENDICARE HEALTH FACILITIES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MAPLE RIDGE HEALTH AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2730 W RAMSEY AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532214814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142822600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2730 W RAMSEY AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532214814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142822600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 04/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | MAASSEN | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CORPORATE COMPLIANCE | ||||||||
| AuthorizedOfficialTelephone: | 4149088119 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 3212 | WI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 20198600 | 05 | WI | MEDICAID |