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General NPI Number Information
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NPI Number | 1649256876
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Entity Type | Organization
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Legal Business Name | MAPLE CREST CARE CENTRE LLC
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Dates
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Enumeration Date | 12/20/2005
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Last Update Date | 02/20/2012
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Provider Practice Location Address
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Address Line | 4452 SQUAW PRAIRIE RD
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City | BELVIDERE
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State | IL
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Zip | 61008-8801
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Country | US
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Telephone | 815-547-6377
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Fax | 815-547-3857
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Provider Business Mailing Address
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Address Line | 4452 SQUAW PRAIRIE RD
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City | BELVIDERE
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State | IL
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Zip | 61008-8801
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Country | US
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Telephone | 815-547-6377
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Fax | 815-547-3857
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Authorized Official
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Title or Position | CONTROLLER
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Name | MR. MICHAEL CHARLES BRAUN
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Credential |
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Telephone | 847-583-0100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 44172
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License Number State | IL
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