Basic Information
Provider Information | |||||||||
NPI: | 1679518377 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TENDERCARE (MICHIGAN) INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TENDERCARE MIDLAND | ||||||||
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: | 4900 HEDGEWOOD DR | ||||||||
Address2: |   | ||||||||
City: | MIDLAND | ||||||||
State: | MI | ||||||||
PostalCode: | 486401928 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9896319670 | ||||||||
FaxNumber: | 9896316899 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/17/2006 | ||||||||
LastUpdateDate: | 07/21/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MAASSEN | ||||||||
AuthorizedOfficialFirstName: | DONNA | ||||||||
AuthorizedOfficialMiddleName: | J. | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF CORPORATE COMPLIANCE | ||||||||
AuthorizedOfficialTelephone: | 4149088119 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 564030 | MI | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 605365318 | 05 | MI |   | MEDICAID | 602617270 | 05 | MI |   | MEDICAID |