Provider Demographics
NPI:1457492332
Name:MAPLE STAR NEVADA LLC
Entity Type:Organization
Organization Name:MAPLE STAR NEVADA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANTOINETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:POULSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-677-2216
Mailing Address - Street 1:855 W 7TH ST STE 160
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503-2706
Mailing Address - Country:US
Mailing Address - Phone:775-677-2216
Mailing Address - Fax:775-322-4460
Practice Address - Street 1:855 W 7TH ST STE 160
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-2706
Practice Address - Country:US
Practice Address - Phone:775-677-2216
Practice Address - Fax:775-322-4460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100508114Medicaid