Healthcare Provider Details

I. General information

NPI: 1851397707
Provider Name (Legal Business Name): MAPLE WINDS CARE CENTER CO. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 02/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4112 SPRINGHILL ROAD
PORTAGE PA
15946
US

IV. Provider business mailing address

4112 SPRINGHILL ROAD
PORTAGE PA
15946
US

V. Phone/Fax

Practice location:
  • Phone: 814-736-6000
  • Fax: 814-736-4299
Mailing address:
  • Phone: 814-736-6000
  • Fax: 814-736-4299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number09750201
License Number StatePA

VIII. Authorized Official

Name: MR. JERRY WILLIAM OTTO
Title or Position: ADMINISTRATOR
Credential: NHA
Phone: 814-736-6000