Provider Demographics
NPI:1790814176
Name:MAPLEWOOD FARM GROUP HOME
Entity Type:Organization
Organization Name:MAPLEWOOD FARM GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSMISKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-665-9336
Mailing Address - Street 1:1503 E NORTHTOWN RD
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-2080
Mailing Address - Country:US
Mailing Address - Phone:660-665-9336
Mailing Address - Fax:660-665-9336
Practice Address - Street 1:1503 E NORTHTOWN RD
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-2080
Practice Address - Country:US
Practice Address - Phone:660-665-9336
Practice Address - Fax:660-665-9336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-03
Last Update Date:2008-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO5622-8623320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO853677607Medicaid