Provider Demographics
NPI:1053308734
Name:MAPLE MANOR NURSING CENTER, INC
Entity type:Organization
Organization Name:MAPLE MANOR NURSING CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:KUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-561-3200
Mailing Address - Street 1:300 VILLA DR
Mailing Address - Street 2:
Mailing Address - City:HURLEY
Mailing Address - State:WI
Mailing Address - Zip Code:54534-1523
Mailing Address - Country:US
Mailing Address - Phone:715-561-3200
Mailing Address - Fax:715-561-5556
Practice Address - Street 1:102 2ND ST
Practice Address - Street 2:
Practice Address - City:ONTONAGON
Practice Address - State:MI
Practice Address - Zip Code:49953-1337
Practice Address - Country:US
Practice Address - Phone:906-884-2882
Practice Address - Fax:906-884-2885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI664020313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2082408Medicaid