Provider Demographics
NPI:1457427304
Name:MAPLE KNOLL COMMUNITIES, INC
Entity Type:Organization
Organization Name:MAPLE KNOLL COMMUNITIES, INC
Other - Org Name:MAPLE KNOLL COMMUNITIES HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:FORMAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-782-2411
Mailing Address - Street 1:11100 SPRINGFIELD PIKE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-4112
Mailing Address - Country:US
Mailing Address - Phone:513-782-2546
Mailing Address - Fax:513-782-8306
Practice Address - Street 1:11100 SPRINGFIELD PIKE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45246-4112
Practice Address - Country:US
Practice Address - Phone:513-782-2546
Practice Address - Fax:513-782-8306
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAPLE KNOLL COMMUNITIES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-24
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0621670Medicaid