Provider Demographics
NPI:1275721268
Name:MAPLE RIDGE ASSISTED LIVING COMMUNITY LLC
Entity Type:Organization
Organization Name:MAPLE RIDGE ASSISTED LIVING COMMUNITY LLC
Other - Org Name:MAPLE RIDGE ASSISTED LIVING COMMUNITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO AND PRESIDENT OF MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-566-5715
Mailing Address - Street 1:1767 ALLIANCE AVE
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:WA
Mailing Address - Zip Code:98249-9448
Mailing Address - Country:US
Mailing Address - Phone:360-331-1303
Mailing Address - Fax:360-331-1363
Practice Address - Street 1:3220 STATE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-6872
Practice Address - Country:US
Practice Address - Phone:503-566-5715
Practice Address - Fax:503-588-3531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1966302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization