Provider Demographics
NPI:1053306019
Name:MAPLE MANOR REHABILITATION CENTER LLC
Entity Type:Organization
Organization Name:MAPLE MANOR REHABILITATION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/ MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANGELISTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-727-0440
Mailing Address - Street 1:3999 VENOY RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-1485
Mailing Address - Country:US
Mailing Address - Phone:734-727-0440
Mailing Address - Fax:734-727-0441
Practice Address - Street 1:3999 VENOY RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-1485
Practice Address - Country:US
Practice Address - Phone:734-727-0440
Practice Address - Fax:734-727-0441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-15
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI235613314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI09896OtherBCBS
MI09896OtherBCBS