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General NPI Number Information
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NPI Number | 1144650045
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Entity Type | Organization
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Legal Business Name | MAPLE RIDGE MANOR, INC
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Dates
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Enumeration Date | 11/14/2013
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Last Update Date | 11/14/2013
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Provider Practice Location Address
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Address Line | 705 LAKE RD
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City | DYERSBURG
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State | TN
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Zip | 38024-2918
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Country | US
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Telephone | 731-286-6725
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Fax | 731-286-6977
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Provider Business Mailing Address
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Address Line | 705 LAKE RD
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City | DYERSBURG
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State | TN
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Zip | 38024-2918
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Country | US
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Telephone | 731-286-6725
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Fax | 731-286-6977
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. BILL ABLES
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Credential |
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Telephone | 731-286-6725
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | ACL0000000212
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License Number State | TN
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