1417021098 NPI number — EXTENDICARE HOMES, INC.

Table of content: (NPI 1417021098)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417021098 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:
1417021098
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/18/2009
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:
124 W NASHVILLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEMBROKE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42266-9763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-475-4227
Provider Business Practice Location Address Fax Number:
270-475-4173
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: 12504809 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 12500880 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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