Basic Information
| Provider Information | |||||||||
| NPI: | 1144222050 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOSPICE ADVANTAGE, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HOME ADVANTAGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 401 CENTER AVE | ||||||||
| Address2: | |||||||||
| City: | BAY CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487085939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898912206 | ||||||||
| FaxNumber: | 9898935268 | ||||||||
| Practice Location | |||||||||
| Address1: | 21415 CIVIC CENTER DR | ||||||||
| Address2: | SUITE 122 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480763909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484401301 | ||||||||
| FaxNumber: | 2484401302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 02/23/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MYNSBERGE | ||||||||
| AuthorizedOfficialFirstName: | KAYEANNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 9898912206 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 15-5192557 | 05 | MI | MEDICAID |