=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366973349
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAPLEWOOD AT CHARDON, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2017
-----------------------------------------------------
Last Update Date | 03/22/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12350 BASS LAKE RD
-----------------------------------------------------
City | CHARDON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44024-8336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-285-3300
-----------------------------------------------------
Fax | 440-286-1024
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 GORHAM IS SUITE 100
-----------------------------------------------------
City | WESTPORT
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06880-3217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-557-4777
-----------------------------------------------------
Fax | 203-557-4783
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | GREGORY D SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 203-557-4777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------