Healthcare Provider Details

I. General information

NPI: 1962686444
Provider Name (Legal Business Name): MAPLE LTC GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 03/24/2020
Certification Date: 03/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1170 LINKHAW RD
LUMBERTON NC
28358-2524
US

IV. Provider business mailing address

1435 HIGHWAY 258N
KINSTON NC
28504-7208
US

V. Phone/Fax

Practice location:
  • Phone: 910-671-1163
  • Fax: 910-671-1448
Mailing address:
  • Phone: 252-523-9094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberNH0472
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License NumberNH0472
License Number StateNC

VIII. Authorized Official

Name: GALE BOICE
Title or Position: CFO
Credential:
Phone: 252-523-9094