MEDICARE: EXTENDICARE HOMES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1184798712
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXTENDICARE HOMES, INC.

Provider Business Mailing Address
First Line	:	111 W MICHIGAN ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53203-2903
Country	:	US
Telephone Number	:	414-908-8119
Fax Number	:	414-908-7105

Provider Business Practice Location Address
First Line	:	4415 W 36 1/2 ST
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-4854
Country	:	US
Telephone Number	:	952-927-9717
Fax Number	:	952-927-7687

Authorized Official
Title or Position	:	DIRECTOR OF COMPLIANCE
Name	:	DONNA JO MAASSEN
Credential	:
Telephone Number	:	414-908-8119

Provider Enumeration Date	:	11/17/2006
Last Update Date	:	03/30/2008

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