1184798779 NPI number — EXTENDICARE HOMES, INC.

Table of content: (NPI 1184798779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184798779 NPI number — EXTENDICARE HOMES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXTENDICARE HOMES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184798779
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 W MICHIGAN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53203-2903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-908-8119
Provider Business Mailing Address Fax Number:
414-908-7105

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7727 PORTLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHFIELD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55423-4320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-861-1691
Provider Business Practice Location Address Fax Number:
612-861-0186
Provider Enumeration Date:
11/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MAASSEN
Authorized Official First Name:
DONNA
Authorized Official Middle Name:
JO
Authorized Official Title or Position:
DIRECTOR OF COMPLIANCE
Authorized Official Telephone Number:
414-908-8119

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 08034300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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