=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609143817
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAPLE ESPLANADE LC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2011
-----------------------------------------------------
Last Update Date | 11/17/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 OLD BERGMAN RD
-----------------------------------------------------
City | HARRISON
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-705-2400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3720 E 2ND ST
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73034-7303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-705-2400
-----------------------------------------------------
Fax | 405-705-2401
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARY YOUNT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 405-705-2400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------