Provider Demographics
NPI:1992825848
Name:SSC STATESVILLE MAPLE LEAF OPERATING COMPANY LLC
Entity Type:Organization
Organization Name:SSC STATESVILLE MAPLE LEAF OPERATING COMPANY LLC
Other - Org Name:MAPLE LEAF HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIRECTOR AR
Authorized Official - Prefix:
Authorized Official - First Name:KELLE
Authorized Official - Middle Name:C
Authorized Official - Last Name:SANTORO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-467-5728
Mailing Address - Street 1:5300 W SAM HOUSTON PKWY N
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77041-5161
Mailing Address - Country:US
Mailing Address - Phone:832-467-6000
Mailing Address - Fax:
Practice Address - Street 1:1101 MAPLE CARE LANE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-8256
Practice Address - Country:US
Practice Address - Phone:704-871-0705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-31
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0488311Z00000X, 311ZA0620X, 313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3426265Medicaid
NC3425340Medicaid
NC7801592Medicaid
NC345340Medicare Oscar/Certification