1487608063 NPI number — HOSPICE ADVANTAGE, LLC

Table of content: (NPI 1487608063)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487608063 NPI number — HOSPICE ADVANTAGE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOSPICE ADVANTAGE, LLC
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:
1487608063
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 CENTER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAY CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48708-5962
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-891-2206
Provider Business Mailing Address Fax Number:
989-893-5268

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1155 QUAIL CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53072-3780
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-786-9002
Provider Business Practice Location Address Fax Number:
262-786-9003
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MYNSBERGE
Authorized Official First Name:
KAYANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
262-786-9002

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 43114300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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