Provider Demographics
NPI:1487669115
Name:EXTENDICARE, INC
Entity Type:Organization
Organization Name:EXTENDICARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:DENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-793-1177
Mailing Address - Street 1:PMB 391
Mailing Address - Street 2:104 APPLE AVE SUITE 3
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303
Mailing Address - Country:US
Mailing Address - Phone:334-793-1177
Mailing Address - Fax:334-699-3948
Practice Address - Street 1:950 S SAINT ANDREWS ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3684
Practice Address - Country:US
Practice Address - Phone:334-793-1177
Practice Address - Fax:334-699-3948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALN3501314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL4757020SMedicaid
AL0762630001Medicare NSC
AL4757020SMedicaid