Provider Demographics
NPI:1205234572
Name:MAPLE KNOLL OUTREACH SERVICES
Entity type:Organization
Organization Name:MAPLE KNOLL OUTREACH SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-686-1004
Mailing Address - Street 1:11275 SPRINGFIELD PIKE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-4113
Mailing Address - Country:US
Mailing Address - Phone:513-984-1234
Mailing Address - Fax:513-686-1040
Practice Address - Street 1:11275 SPRINGFIELD PIKE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45246-4113
Practice Address - Country:US
Practice Address - Phone:513-984-1234
Practice Address - Fax:513-686-1040
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAPLE KNOLL COMMUNITIES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-12-18
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1623343900000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0790550Medicaid