Provider Demographics
NPI:1871614859
Name:MAPLE GROVE NURSING HOME INC
Entity type:Organization
Organization Name:MAPLE GROVE NURSING HOME INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-532-6593
Mailing Address - Street 1:93 MILITARY ST
Mailing Address - Street 2:
Mailing Address - City:HOULTON
Mailing Address - State:ME
Mailing Address - Zip Code:04730-2421
Mailing Address - Country:US
Mailing Address - Phone:207-532-6593
Mailing Address - Fax:207-532-4456
Practice Address - Street 1:93 MILITARY ST
Practice Address - Street 2:
Practice Address - City:HOULTON
Practice Address - State:ME
Practice Address - Zip Code:04730-2421
Practice Address - Country:US
Practice Address - Phone:207-532-6593
Practice Address - Fax:207-532-4456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251J00000X, 261QA0600X
ME2054313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No251J00000XAgenciesNursing Care
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME105630000Medicaid