=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407308026
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTELICARE HOSPICE SERVICES II, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2016
-----------------------------------------------------
Last Update Date | 09/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 604 W MAIN ST STE A
-----------------------------------------------------
City | GAYLORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49735-1869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-421-5285
-----------------------------------------------------
Fax | 231-421-5281
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6170 US HIGHWAY 31 N UNIT B
-----------------------------------------------------
City | WILLIAMSBURG
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49690-8308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-421-5285
-----------------------------------------------------
Fax | 231-421-5281
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF COMPLIANCE OFFICER
-----------------------------------------------------
Name | VALERIE JO DEWBRE
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 214-534-0716
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251G00000X
-----------------------------------------------------
Taxonomy Name | Community Based Hospice Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------