Provider Demographics
NPI:1124192752
Name:EXTENDICARE HOMES, INC.
Entity Type:Organization
Organization Name:EXTENDICARE HOMES, INC.
Other - Org Name:FORDSVILLE NURSING & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:MAASSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-908-8119
Mailing Address - Street 1:111 W MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53203-2903
Mailing Address - Country:US
Mailing Address - Phone:414-908-8119
Mailing Address - Fax:414-908-7105
Practice Address - Street 1:313 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FORDSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42343-9763
Practice Address - Country:US
Practice Address - Phone:270-276-3603
Practice Address - Fax:270-276-3031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY12501730Medicaid
KY185354Medicare Oscar/Certification