Provider Demographics
NPI:1114492519
Name:MAPLE HOLLOW REHABILITATION AND NURSING LLC
Entity Type:Organization
Organization Name:MAPLE HOLLOW REHABILITATION AND NURSING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-709-4358
Mailing Address - Street 1:34 NE 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-3019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34 NE 20TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-3019
Practice Address - Country:US
Practice Address - Phone:503-231-0276
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-11
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility