Basic Information
| Provider Information | |||||||||
| NPI: | 1144526641 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOSPICE ADVANTAGE, LLC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HOSPICE ADVANTAGE, INC. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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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: | 2620 FORUM BLVD | ||||||||
| Address2: | SUITE E | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652035454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734429104 | ||||||||
| FaxNumber: | 5734429124 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2011 | ||||||||
| LastUpdateDate: | 07/02/2014 | ||||||||
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| AuthorizedOfficialLastName: | MYNSBERGE | ||||||||
| AuthorizedOfficialFirstName: | KAYE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 9898912210 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 203-HO | MO | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 1144526641 | 05 | MO | MEDICAID |