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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1861566564
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	:	3650 KLEPINGER RD
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45416-1919
Country	:	US
Telephone Number	:	937-278-0663
Fax Number	:	937-278-1977

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	:	08/22/2020

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