Provider Demographics
NPI:1003022963
Name:MAPLE GROVE SENIOR LIVING
Entity Type:Organization
Organization Name:MAPLE GROVE SENIOR LIVING
Other - Org Name:MAPLE GROVE SENIOR LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDERVEER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-856-2757
Mailing Address - Street 1:1917 S 18TH ST
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52544-3136
Mailing Address - Country:US
Mailing Address - Phone:641-856-2757
Mailing Address - Fax:641-856-2762
Practice Address - Street 1:1917 S 18TH ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:IA
Practice Address - Zip Code:52544-3136
Practice Address - Country:US
Practice Address - Phone:641-856-2757
Practice Address - Fax:641-856-2762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAS0088310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0262576Medicaid