Healthcare Provider Details

I. General information

NPI: 1588784136
Provider Name (Legal Business Name): MAPLE HOUSE SHELTER CARE HOME, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 E 3RD ST
JOHNSTON CITY IL
62951-1624
US

IV. Provider business mailing address

205 E 3RD ST PO BOX 230
JOHNSTON CITY IL
62951-1624
US

V. Phone/Fax

Practice location:
  • Phone: 618-983-5731
  • Fax: 618-983-7101
Mailing address:
  • Phone: 618-983-5731
  • Fax: 618-983-7101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number0038380
License Number StateIL

VIII. Authorized Official

Name: MS. RHONDA L. JONES
Title or Position: PRESIDENT
Credential:
Phone: 618-983-5731