Basic Information
Provider Information | |||||||||
NPI: | 1487608063 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HOSPICE ADVANTAGE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HOSPICE ADVANTAGE, INC | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 401 CENTER AVE | ||||||||
Address2: |   | ||||||||
City: | BAY CITY | ||||||||
State: | MI | ||||||||
PostalCode: | 487085962 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9898912206 | ||||||||
FaxNumber: | 9898935268 | ||||||||
Practice Location | |||||||||
Address1: | 1155 QUAIL CT | ||||||||
Address2: |   | ||||||||
City: | PEWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 530723780 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2627869002 | ||||||||
FaxNumber: | 2627869003 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/19/2006 | ||||||||
LastUpdateDate: | 01/15/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MYNSBERGE | ||||||||
AuthorizedOfficialFirstName: | KAYANNE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | COO | ||||||||
AuthorizedOfficialTelephone: | 2627869002 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X |   |   | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 43114300 | 05 | WI |   | MEDICAID |