Basic Information
| Provider Information | |||||||||
| NPI: | 1669417473 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TENDERCARE MICHIGAN INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | TENDERCARE PORTAGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 111 W MICHIGAN ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532032903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149088119 | ||||||||
| FaxNumber: | 4149088481 | ||||||||
| Practice Location | |||||||||
| Address1: | 7855 CURRIER DR | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490024314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693237748 | ||||||||
| FaxNumber: | 2693231908 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 02/19/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | THIEL | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | JO | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF COMPLIANCE | ||||||||
| AuthorizedOfficialTelephone: | 4149088119 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 394180 | MI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 602617304 | 05 | MI | MEDICAID |