Provider Demographics
NPI:1306377197
Name:CPLACE CARTERSVILLE SNF LLC
Entity Type:Organization
Organization Name:CPLACE CARTERSVILLE SNF LLC
Other - Org Name:MAPLE RIDGE HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:M
Authorized Official - Last Name:MARCOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-209-1431
Mailing Address - Street 1:24641 US HIGHWAY 19 N
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33763-5007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22 MAPLE RIDGE DR SE
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30121-2228
Practice Address - Country:US
Practice Address - Phone:770-606-8800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-23
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-077-1331314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA115543Medicare Oscar/Certification