Provider Demographics
NPI:1558446823
Name:MAPLE PLACE LIVING CENTER, LLC
Entity Type:Organization
Organization Name:MAPLE PLACE LIVING CENTER, LLC
Other - Org Name:MAPLE PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:R
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-380-6671
Mailing Address - Street 1:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:WELEETKA
Mailing Address - State:OK
Mailing Address - Zip Code:74880-0488
Mailing Address - Country:US
Mailing Address - Phone:405-786-2266
Mailing Address - Fax:405-786-2388
Practice Address - Street 1:620 S ALABAMA ST
Practice Address - Street 2:
Practice Address - City:WETUMKA
Practice Address - State:OK
Practice Address - Zip Code:74883-6033
Practice Address - Country:US
Practice Address - Phone:405-452-3271
Practice Address - Fax:405-452-5154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH3207-3207315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200101970AMedicaid