Provider Demographics
NPI:1851738652
Name:MAPLE MANOR REHAB CENTER OF NOVI INC.
Entity Type:Organization
Organization Name:MAPLE MANOR REHAB CENTER OF NOVI INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATTORNEY AND CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANGELISTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-320-9114
Mailing Address - Street 1:7071 ORCHARD LAKE RD
Mailing Address - Street 2:SUITE 333
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3613
Mailing Address - Country:US
Mailing Address - Phone:248-626-1114
Mailing Address - Fax:248-626-3918
Practice Address - Street 1:31215 NOVI RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377
Practice Address - Country:US
Practice Address - Phone:248-626-1114
Practice Address - Fax:248-626-3918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-03
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI634595314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility