MEDICARE: MAPLE HEALTHCARE CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1104539956
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAPLE HEALTHCARE CENTER LLC

Provider Business Mailing Address
First Line	:	2625 MAPLE AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90011-1431
Country	:	US
Telephone Number	:	213-948-0193
Fax Number	:	213-747-1615

Provider Business Practice Location Address
First Line	:	2625 MAPLE AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90011-1431
Country	:	US
Telephone Number	:	213-948-0193
Fax Number	:	213-747-1615

Authorized Official
Title or Position	:	MANAGER
Name	:	EZEQUIEL BERCOVICH
Credential	:
Telephone Number	:	213-948-0193

Provider Enumeration Date	:	12/26/2022
Last Update Date	:	12/26/2022

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Directions to “MAPLE HEALTHCARE CENTER LLC ” Practice Location

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