Basic Information
| Provider Information | |||||||||
| NPI: | 1568591733 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TENDERCARE MICHIGAN INC. | ||||||||
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| OtherOrganizationName: | TENDERCARE HEALTH CENTER OF WYOMING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 W MICHIGAN ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532032903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149088119 | ||||||||
| FaxNumber: | 4149088481 | ||||||||
| Practice Location | |||||||||
| Address1: | 2786 56TH ST SW | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494188708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162613690 | ||||||||
| FaxNumber: | 6162613925 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 02/19/2014 | ||||||||
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| AuthorizedOfficialLastName: | THIEL | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | JO | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF COMPLIANCE | ||||||||
| AuthorizedOfficialTelephone: | 4149088119 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 414384 | MI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 605204498 | 05 | MI | MEDICAID |