=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033420641
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAPLE MANAGEMENT LC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2010
-----------------------------------------------------
Last Update Date | 06/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3 SW 1ST LN
-----------------------------------------------------
City | LAMAR
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64759-1772
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-682-6184
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 SW 1ST LN
-----------------------------------------------------
City | LAMAR
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64759-1772
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-682-6184
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | MARY YOUNT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 405-705-2420
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 038233
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------