MEDICARE: MAPLE WINDS CARE CENTER CO. LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	09750201	PA

General Provider Information

NPI Number	:	1851397707
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAPLE WINDS CARE CENTER CO. LLC

Provider Business Mailing Address
First Line	:	4112 SPRINGHILL ROAD
Second Line	:
City	:	PORTAGE
State	:	PA
Zip	:	15946
Country	:	US
Telephone Number	:	814-736-6000
Fax Number	:	814-736-4299

Provider Business Practice Location Address
First Line	:	4112 SPRINGHILL ROAD
Second Line	:
City	:	PORTAGE
State	:	PA
Zip	:	15946
Country	:	US
Telephone Number	:	814-736-6000
Fax Number	:	814-736-4299

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. JERRY WILLIAM OTTO
Credential	:	NHA
Telephone Number	:	814-736-6000

Provider Enumeration Date	:	06/24/2005
Last Update Date	:	02/24/2010

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