Provider Demographics
NPI:1144223587
Name:MAPLE VALLEY NURSING HOME OF MAPLE CITY, INC.
Entity Type:Organization
Organization Name:MAPLE VALLEY NURSING HOME OF MAPLE CITY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER/VICE-PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KASBEN
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:231-228-5895
Mailing Address - Street 1:1086 W BURDICKVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MAPLE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49664-8769
Mailing Address - Country:US
Mailing Address - Phone:231-228-5895
Mailing Address - Fax:231-228-7512
Practice Address - Street 1:1086 W BURDICKVILLE RD
Practice Address - Street 2:
Practice Address - City:MAPLE CITY
Practice Address - State:MI
Practice Address - Zip Code:49664-8769
Practice Address - Country:US
Practice Address - Phone:231-228-5895
Practice Address - Fax:231-228-7512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI454010314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1909799Medicaid
MI09960OtherBCBSM PROVIDER ID
MI1909799Medicaid
MI235588Medicare UPIN