Provider Demographics
NPI:1205183449
Name:MAPLE RIDGE LIVING CENTER
Entity Type:Organization
Organization Name:MAPLE RIDGE LIVING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/LICENSEE
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KUNKEL
Authorized Official - Suffix:
Authorized Official - Credentials:231-839-1011
Authorized Official - Phone:231-839-1011
Mailing Address - Street 1:2575 W HOUGHTON LAKE RD
Mailing Address - Street 2:P.O. BOX 677
Mailing Address - City:LAKE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49651-8820
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2575 W HOUGHTON LAKE RD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:MI
Practice Address - Zip Code:49651-8820
Practice Address - Country:US
Practice Address - Phone:231-839-1011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAL570303169261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center