MEDICARE: MAPLE SPRINGS, 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	310400000X	Assisted Living Facility	102056	UT

General Provider Information

NPI Number	:	1841568128
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAPLE SPRINGS, LLC

Provider Business Mailing Address
First Line	:	1040 MEDICAL DR
Second Line	:
City	:	BRIGHAM CITY
State	:	UT
Zip	:	84302-5599
Country	:	US
Telephone Number	:	435-723-9100
Fax Number	:	435-723-9150

Provider Business Practice Location Address
First Line	:	1040 MEDICAL DR
Second Line	:
City	:	BRIGHAM CITY
State	:	UT
Zip	:	84302-5599
Country	:	US
Telephone Number	:	435-723-9100
Fax Number	:	435-723-9150

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	NICHOLAS ADAM LARSEN
Credential	:
Telephone Number	:	435-723-9100

Provider Enumeration Date	:	12/01/2011
Last Update Date	:	12/01/2011

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Directions to “MAPLE SPRINGS, LLC ” Practice Location

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