Provider Demographics
NPI:1548214315
Name:KEWEENAW HOME NURSING, INC.
Entity Type:Organization
Organization Name:KEWEENAW HOME NURSING, INC.
Other - Org Name:KEWEENAW HOME NURSING & HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KOLB
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:906-337-5700
Mailing Address - Street 1:311 6TH ST
Mailing Address - Street 2:
Mailing Address - City:CALUMET
Mailing Address - State:MI
Mailing Address - Zip Code:49913-1507
Mailing Address - Country:US
Mailing Address - Phone:906-337-5700
Mailing Address - Fax:906-337-9929
Practice Address - Street 1:311 6TH ST
Practice Address - Street 2:
Practice Address - City:CALUMET
Practice Address - State:MI
Practice Address - Zip Code:49913-1507
Practice Address - Country:US
Practice Address - Phone:906-337-5700
Practice Address - Fax:906-337-9929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI14333251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI08730OtherBCBSM HOSPICE PROVIDER
MI2996476Medicaid
MI2996476Medicaid