Basic Information
| Provider Information | |||||||||
| NPI: | 1437126265 | ||||||||
| 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: | 487085962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898912206 | ||||||||
| FaxNumber: | 9898935268 | ||||||||
| Practice Location | |||||||||
| Address1: | 1309 S LINDEN RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107339975 | ||||||||
| FaxNumber: | 8107339476 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2006 | ||||||||
| LastUpdateDate: | 01/15/2013 | ||||||||
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| AuthorizedOfficialLastName: | MYNSBERGE | ||||||||
| AuthorizedOfficialFirstName: | KAYANNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 9898912210 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 253520 | MI | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 15-4844384 | 05 | MI | MEDICAID | 08745 | 01 | MI | BLUE CROSS OF MICHIGAN | OTHER | 01002968 | 01 | MI | HEALTH PLUS OF MICHIGAN | OTHER |