Provider Demographics
NPI:1851397707
Name:MAPLE WINDS CARE CENTER CO. LLC
Entity Type:Organization
Organization Name:MAPLE WINDS CARE CENTER CO. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:OTTO
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:814-736-6000
Mailing Address - Street 1:4112 SPRINGHILL ROAD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:PA
Mailing Address - Zip Code:15946
Mailing Address - Country:US
Mailing Address - Phone:814-736-6000
Mailing Address - Fax:814-736-4299
Practice Address - Street 1:4112 SPRINGHILL ROAD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:PA
Practice Address - Zip Code:15946
Practice Address - Country:US
Practice Address - Phone:814-736-6000
Practice Address - Fax:814-736-4299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA09750201314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
396088Medicare ID - Type Unspecified