Healthcare Provider Details

I. General information

NPI: 1417021098
Provider Name (Legal Business Name): EXTENDICARE HOMES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 09/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 W NASHVILLE ST
PEMBROKE KY
42266-9763
US

IV. Provider business mailing address

111 W MICHIGAN ST
MILWAUKEE WI
53203-2903
US

V. Phone/Fax

Practice location:
  • Phone: 270-475-4227
  • Fax: 270-475-4173
Mailing address:
  • Phone: 414-908-8119
  • Fax: 414-908-7105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: DONNA JO MAASSEN
Title or Position: DIRECTOR OF COMPLIANCE
Credential:
Phone: 414-908-8119