Provider Demographics
NPI:1801364393
Name:BEARMT MAPLE LANE
Entity Type:Organization
Organization Name:BEARMT MAPLE LANE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WYNNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-904-7462
Mailing Address - Street 1:60 MAPLE LN
Mailing Address - Street 2:
Mailing Address - City:BARTON
Mailing Address - State:VT
Mailing Address - Zip Code:05822-9494
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:60 MAPLE LN
Practice Address - Street 2:
Practice Address - City:BARTON
Practice Address - State:VT
Practice Address - Zip Code:05822-9494
Practice Address - Country:US
Practice Address - Phone:802-754-2112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEAR MOUNTAIN HEALTHCARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility