Basic Information
| Provider Information | |||||||||
| NPI: | 1932427309 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EXTENDICARE HEALTH FACILITIES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MICHIANA HEALTH AND REHABILITATION CENTER | ||||||||
| 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: | 4149087105 | ||||||||
| Practice Location | |||||||||
| Address1: | 1420 E DOUGLAS ROAD | ||||||||
| Address2: | |||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465451733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022166344 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2010 | ||||||||
| LastUpdateDate: | 04/28/2011 | ||||||||
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| AuthorizedOfficialLastName: | MAASSEN | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF COMPLIANCE | ||||||||
| AuthorizedOfficialTelephone: | 4149088119 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 201002500 | 05 | IN | MEDICAID |