Healthcare Provider Details

I. General information

NPI: 1871774455
Provider Name (Legal Business Name): MAPLE RIDGE RETIREMENT & ASSISTED LIVING COMMUNITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2007
Last Update Date: 11/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1767 ALLIANCE AVE
FREELAND WA
98249-9448
US

IV. Provider business mailing address

3220 STATE ST SUITE 200
SALEM OR
97301-6872
US

V. Phone/Fax

Practice location:
  • Phone: 360-331-1303
  • Fax: 360-331-1363
Mailing address:
  • Phone: 503-373-3125
  • Fax: 503-588-3531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number1966
License Number StateWA

VIII. Authorized Official

Name: MR. KELLEY D HAMILTON
Title or Position: CEO/PRESIDENT OF MANAGEMENT COMPANY
Credential:
Phone: 503-373-3125