Basic Information
| Provider Information | |||||||||
| NPI: | 1306883947 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOSPICE ADVANTAGE, LLC | ||||||||
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| OtherOrganizationName: | HOSPICE ADVANTAGE, INC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 CADILLAC DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178414834 | ||||||||
| FaxNumber: | 8669558538 | ||||||||
| Practice Location | |||||||||
| Address1: | 1026 S TAYLOR DR | ||||||||
| Address2: | |||||||||
| City: | SHEBOYGAN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530814773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204521851 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 04/25/2018 | ||||||||
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| AuthorizedOfficialLastName: | ADKINS | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
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| AuthorizedOfficialTitleorPosition: | SVP GENERAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 6153095668 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 2012 | WI | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 43190400 | 05 | WI | MEDICAID |