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General NPI Number Information
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NPI Number | 1558446823
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Entity Type | Organization
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Legal Business Name | MAPLE PLACE LIVING CENTER, LLC
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Dates
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Enumeration Date | 10/26/2006
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Last Update Date | 01/12/2023
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Provider Practice Location Address
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Address Line | 620 S ALABAMA ST
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City | WETUMKA
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State | OK
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Zip | 74883-6033
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Country | US
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Telephone | 405-452-3271
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Fax | 405-452-5154
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Provider Business Mailing Address
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Address Line | PO BOX 488
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City | WELEETKA
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State | OK
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Zip | 74880-0488
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Country | US
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Telephone | 405-786-2266
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Fax | 405-786-2388
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. DONNA R SIMMONS
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Credential |
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Telephone | 405-380-6671
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | NH3207-3207
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License Number State | OK
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